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NORTH  CAROLINA 
MEDICAL  JOURNAL. 


A  SEI»II.I»IOXTHI.Y  JOCRXAL  OF  IWEDICIINE  A\D 
SURGERY. 


-EDITED    BY- 


ROBERT   D.    JEWETT,    M.  D. 


VOLUME  XEI. 

JANUARY  TO  J^fe¥  iS 


WINSTON,    N.   C, 

CAROLINA  PUBLISHING  COMPANY, 
1898. 


INDEX  BY  AUTHORS. 

Anderson,  Albert,  M.  D.— Annual  Oration— Two  southern  pioneer  heroes  in 

surgery  and  gynecology,  290 
Battle,  K.  P.,  M.  D.— A  shawl  pin  in  the  trachea,  409 
Blount,  J.  G.,  M.  D.— The  chemistry  of  the  stomach,  38S 
Hrownson,  W.  C,  M.  D.— The  tobacco  habit  a  cause  of  disease,  345 

Burroughs,  J.  A.,  M.  D. — A  few  suggestions  on  the  prevention  of  tubercu- 
losis, 356 

Davidson,  W.  Sinclair,  M.  D.— Excision  of  the  gall-bladder  for  impacted 
gall-stone,  421 

Duffy,  Francis,  M.  D.— President's  address,   2S1 

Fletcher,  M.  H.,  M.  D. — Report  on  practice  of  medicine,  350 

Goelet,  Augustine  H.,  M.  D. — Abdominal  hysterectomy  for  large  submucous 
fibroid  of    the  uterus — ventral  suspension  of  the  uterus  for  fixed  retro- 
flexion, 112 
Abdominal  myomectomy — vaginal  ligation  and  division  of  the    uterine 

arteries  for  fibroid  of  the  anterior  uterine  wall,  445 
Conservative  oophorectomy,  245 

Shortening  the  round  ligaments  by  a  new  method  for  reducible  retroflexion 
of  the  uterus,  179 

Graham,  St.  Joseph  P.,  M.  D. — Puerperal  infection,  5 

Hill,  D.  J.,  M.  D. — Veratrum  'viride,  with  especial  reference  to  its  thera- 
peutic uses  in  serous  and  parenchymatous  inflammations,  396 

Lankford,  Livius,  M.  D. — Drainage  after  labor,  loi 

Lett,  H.  S. ,  M.  D. — Meddlesome  gynecology,  373 

Marter,  J.  G.  Van,  Jr.,  M.  D. — Quinine  in  malarias  excluding  the  simple 
intermittents,  65 

McGinnis,  R.  H. ,  M.  D. — Some  thoughts  on  typhoid  fever,  436 

Moore,  E.  G.,  M.  D. — Some  reflections  on  post  graduate  instruction,  297 

Monroe,  J.  P.,  M.  D. — Some  observations  on  the  radical  cure  of  inguinal 
hernia,  with  report  of  an  unusual  case,  406 

Myers,  Harry  L.,  M.  D. — Hypertrophy  of  the  pharyngeal  tonsil,  or  adenoids 
of  the  naso-pharynx,  106 

Noer,  J.,  M.  D. — The  use  of  the  sharp  curette  in  septic  infection  after  labor 
and  abortion,  i 

Parrott,  J.  M.,  M.  D. — The  country  surgeon  and  his  work,  399 

Pope,  Curran,  M.  D.— Neurasthenia,  145 

Price,  Mordecai,  M.  D. — Extra-uterine  pregnancy,  431 

Riddick,  Thomas  M.,  M.  D. — In  the  matter  of  doctors  and  pants,  74 
Typhoid  fever  and  its  treatment,  209 

Royster,  H.  A.,  M.  D.— The  under  side  of  things  in  a  doctor's  life,  338 

Smith  wick,  J.  W.  P.,  M.  D.— Hemorrhagic  fever — report  of  a  case,  32 

Stafford,  W.  G.,  M.  D.— Report  on  obstetrics,  381 

Stanton,  D.  A.,  M.  D.--Puerpeal  eclampsia  and  its  treatment,  29 

Way,  J.  Howell,  M.  D.— Expert  medical  witnesses — what  is  the  cause  of  the 
seeming  disrepute  in  which  their  testimony  is  held  in  certain  recent  cases 
in  the  courts?  Observations  from  the  standpoint  of  the  country  doctor,  413 

Woodward,  John  F.— Chronic  laryngitis— some  of  its  chief  causes  and  re- 
sults, 137 

INDEX  BY  SUBJECTS. 


Abdominal  hysterectomy  for  large  submucous  fibroid  of  the  uterus,  112 

myomectomy,  443 

section  in  America,  statistics  of  48 
Acting  assistant  surgeons,  316 
Adulteration,  ; 


27 


All  paths  lead  to  the  grave,  26 

Amputation  of  extremities  without  ligatures,  232 

Amymalitic  ferments,  464 

An  appeal,  57 

A  new  amusement  enterprise,  204 

Annual  essay — the  under  side  of  things  in  a  doctor's  life,  338 

oration — two  southern  pioneer  heroes  in  surgery  and  gynecology,  390 
Antikarnnia  calendar,  60 

Age  of  parents  and  its  infinence  on  their  progeny,  241 
A  good  true  story,  240 
An  unique  claim,  98 
Are  you  going  to  Cuba?  371 
Artificial  oysters,  98 
A  sad  event,  201 
A  special  favor,  60 

Athrepsia,  goat's  milk  in  the  treatment  of  169 
Appendicitis,  229 

Bayer's  Pharmaceutical  products,  459 
Bellamy,  Dr.  Russell,  429 
Bellavue  Hospital,  resignation  from  459 
Besieging  a  dispensary,  134 
Big  ones,  240 

Board  of  medical  examiners,  315,  279 
election  of  members  to  227 
questions  submitted  by  the,  at  Charlotte,  426 
Book  Reviews — 

Clinical  diagnosis,  97 

Diseases  of  women,  treatise  on  the  450 

Elements  of  Latin  449 

Flint's  medical  and  surgical  directory,  165 

Health  of  body  and  mind,  94 

Hygiene,  outlines  of  rural  450 

Index  catalogue,    121 

International  medical  annual  '97,  229 

Lectures  on  the  action  of  medicines,  165 

Natural  history,  228 

Sexual  neurasthenia,  425 

Spinal  caries,  95 

Surgery,  a  text-book  on  425 

System  of  medicine,  121 
British  Medical  Journal,  editor  of  134 
Burns,  picric  acid  in  the  treatment  of  162 
Buzzard  in  medicine,  the  172 

Campbell,  Mr.   27 

Can  make  it  a  boy,  78 

Carcinoma  of  the  breast,  87 

Care  of  the  wounded  in  railroad  accidents,  198 

of  the  sick  and  wounded,  316 
Cheap  instruments,  171 
Cobleigh,  Dr.  E.  A.   429 
Collaborators,  our  corps  of  47 
Correction,  430 

Country  surgeon  and  his  work,  the  399 
Craig  colony,  the  progress  at,  during  the  year  27 
Crowell,  Dr.  A.  J.,  429 
Crusto  lactea,  treatment  of  170 
Cuba  the  breeding  ground  of  yellow  fever. 
Curette  in  septic  infection  after  labor  and  abortion,  the  sharp  i 


iv 


INDEX. 


Daligny,  Dr.  C.  274 

Digestive  diseases  in  early  childhood,  a  new  factor  of  169 

Diphtheria  antitoxin,  concentration  461 

"Doc"  132 

Doliber  Goodale  Co.,  459 

Ectopic  gestation,  236 

Empyema,  treatment  of  S6 

Endometritis  chronica,  196 

English  in  prescription  writing,  276 

Enierorrhaphy,  a  new  apparatus  in  125 

Enuresis,  a  contribution  to  the  therapeutics  of  313 

Epileptic  colony,  275 

E.xamination  of  the  blood,  practical  hints  in  132 

E.xpert  medical  witnesses— what  is  the  cause  of  the  disrepute  in   which  their 

testimony  is  held  in  certain  recent  cases  in  the  courts?    Observation  from 

the  standpoint  of  the  country  doctor,  413 
Extra-uterine  prgenancy,  431 

at  term,  a  case  of  combined  intra  and  166 
Eye,  shot  grain  wounds  of  the  87 

Fake  doctors,  460 

Fibroia  in  the  anterior  uterine   wall,    vaginal   ligation   and    division  of  the 

uterine  arteries  for  interstitial  445 
I'^ilter  the  water,  170 

Fistula,  special  care  of  the  sphincter  ani  in  operation  for  88 
Football,  134 

Foreign  bodies  in  the  air  passages,   84 
Franklin,  Dr.  Roscoe  E.   315 

Gall-bladder,  excision  of  the  for  impacted  gall-stone  421 
Gastric  fever,  90 

ulcer,  surgical  treatment  of  230 
Gastrotomy  for  removal  of  foreign  bodies,  249 
Gonorrhoea,  acute,  with  especial  reference  to  its  treatment,  173 
Gun-shot  wounds  of  the  brain  with  recovery,  125 
Gray's  anatomy,  Chinese  edition  of  171 
Gynecology,  a  series  of  clinical  lectures  on   228 

Hand,  injuries  of  the  28 
Harrell,  Dr.  S.  N.  132 
Harrison's,  Dr.  Virginius,  office  170   . 
Heart  disease,  some  don'ts  about  205 
Hemorrhagic  fever,  report  of  two  cases  32 

Hernia,  some  observations  on  the  radical  cure  of  inguinal    with  report  of  an 
unusal  case,  406 

treatment  of,  by  injection  313 
Homing  pidgeons  in  medical  practice,  117 
Hospitals  closed,  278 
Human  nature  in  Ihe  steerage,  242 

Immunity,  233 

for  diptheria,  for  what  period  of  time  can  it  be  obtained  by  a  single 
dose  of  antitoxin  184 
Infantile  scurvy,  128 
Interesting  obstetrical  cases,  129 
International  Jonrnal  of  Surgery,  98         ' 
International  leprosy  convention,  130 


Intestinal  anastomosis,  a  new  method  of  124 
In  the  matter  of  doctors  and  pants,  74 
Is  a  violent  death  painful,  276 

Jones,  Dr.  Robert  DuVal  98 

Klebs,  Dr.  Edwin  243 
Koch's  new  tuberculin,  98,   160 
rinderpest  remedy,  62 

Labor,  drainage  after  loi 

Laparotomy,  management  of  patients  before  and  after  88 

Laryngitis  chronica — some  of  its  chief  causes  and  results,  137 

Lemon  grove  in  the  intestine,  176 

Liquid  air,  223 

Lofeton  islands,  the  61 

Long,  Miss  Margaret  240 

Malarial  haematuria,  271 

Malaria,  papers  on  98 

Matthews,  Dr.  J.  O.   27 

McLeod,  Dr.  A.  H.  239 

Measles,  a  new  diagnostic  sign  in  312 

Meddlesome  gynecolog3S  373 

Medical  and  Surgical  Reporter,  201 

College  of  Virginia,  241,  315 

partners  jointly  responsible,  171 

officers  of  the  army,  316 
Memory,  modern  deterioration  of  278 
Microscope,  an  improved  171 
Midwives  question  in  England,  202 
Mount  Sinai  Hospital,  240 

Nathan  Lewis  Hatfield  prize,  460 
Necrology: 

Brown,  F.  W.,  M.  D.  462 

Crusius,  Louis,  M.  D.   100 

Dismond,  A.  H.,  M.  D.  307 

Dorsat,  Cornelius  N.,  M.   D.  63 

Gibbon,  R.  L.,  M.  D.  371 

Gibbs,  acting  Assistant  Surgeon  John  Blair  458 

Graham,  D.   McL.,  M.  D.  429 

Hart,  Ernest,  M.  D.   100 

Johnston,  W.  H.,  M.  D.  279 

Luck,  Wm.  W.,  M.  D.  307 

McKee,  Jas.  Cooper,  M.  D.  63 

Moore,  Thomas  Jefferson,  M.  D.  307 

Murphy,  J.  S.,  M.  D.   100 

O'Dwyer,  Joseph,  M.  D.   100 

Parvin,  Theophilus,  M.  D.   135 

Pean,  Jules  Emile,  M.  D.   135 

Peurifoy,  A.  W.,  M.  D.  63 

Quain,  Sir  Richard  307 

Rogers,  S.  A.,  M.  D.  100 

Strachan,  A.  Russell,  M.  D.  279 

Strong,  Jno.  Mason,  M.  D.  307 
Neurastheia,  145 
New  books,  266 


INDEX. 

VI 

New  use  for  pills,  26  ... 

New  York  Skin  and  Cancer  Hospital,  240 

North  American  Journal  of  Diagnosis  and  Practice,  132 

Obstetrics,  report  on  3S1 
'•Ole  Doctor  Fisel"  275 
Oophorectomy,  conservative  245 

Parasites  in  the  heart  of  a  dog,  240 

Parrott,  Dr  J.  M.  171 

Passage  of  substances  through  the  placenta,  277 

Paternal  government  of  our  health  board,  243 

Pelvic  inflammations.  213 

pus  accumulations,  suprapubic  vs.  vaginal  section  in  197 
Perineum,  a  new  operation  for  the  repair  of    453 
Perry.  Dr.  M.  P.  27 

Persistent  vitelline  (emphalo  mesenteric)  duct  and  its  consequences,  31 
Pharyngeal  tonsil,  hypertrophy  of,  or  adenoids  of  the  naso-pharynx  106 
Practical  patient,  a  133 
Practice  of  medicine,  report  on  350 
Present  situation,  the  305 
President's  address,  2S1 
Progressive  potentate,  a  61 
Pott's  disease,  a  new  treatment  of  45 
Post  graduate  instruction,  some  reflections  on  297 
operative  ileus.  54 

lesions  and  sequelae,  54 
Puerperal  eclampsia  and  its  treatment,  29 

infection,  5 
Public  service,  the  206,  236,  274 
Puzzling  cases,  275 

Quain,  health  of  Sir  Richard  204 

Queer  vaccination,  241 

Quinine  in  malaria  excluding  the  simple  intermittents,  65 

Rectal  surgery,  the  present  status  of  254 
Removal  notice,  164 

of  the  Journal's  plant,  I96 
Responsibility  of  water  companies,  60 
Roberts,  Dr.  }.  D.  60 
Roentgen  ray  in  North  Carolina,  84 
Rush  Medical  Coliege,  61 

Schleich's  method  of  general  anaesthesia,  264 
Senn,  Dr.  Nicholas  239 
Shock,  conservative  agency  of  231 

Shortening  the    round    ligaments   by  a  new  method  for  reducible  retro-flex- 
ion, 179 
Small-pox,  79 

in  Georgia,  22 

in  Wilmington,  N.  C,  a  case  of  62 
Smithwick,  Dr.  J.  W.  P.    133 
Society  meeting,  the  I95,  369 
reports: 

Clinical  society  of  St.  James'  dispensary,  14 
Medical  Society  of  the  State  of  North  Carolina,  317 


New  York  Academy  of  Medicine,  3g,  148,  219 

Raleigh  Academy  of  Medicine,  10 

Riclimond  Academy  of  Medicine  and  Surgery,  35,  153 

Seaboard  Medical  Association,  81 
Spain's  responsibility,  459 
Spruill,  Dr.  StClair  315 
State  production  of  drugs,  226 
Stomach,  Dr.  Sclatter's  removal  of  the  162 
excision  of  the  132 
the  chemistry  of  the  388 
Strickland,  Dr.  E.  F.  27 

Subcutaneous  testimony  as  an  aid  in  the  reduction  of  fractures,  182 
Survival  of  the  fittest,  193 

The  Georgia  foot-ball  bill,  26 
The  law  of  Malthus  60 
The  new  year,  23 
Therapeutic  Hints: 

Alcohol  instead  of  whiskey,  97 

Alcoholism  acute,   25 

Alopecia,  201 

Antineuralgic  liniments.  273 

Bronchitis,  acute  catarrhal  200 

Coryza,  treatment  of  in  childhood  200 

Curettage,  98 

Dilivery  by  forceps,  25 

Diphthe-ia  antitoxin  by  the  stomach,  201 

Ear,  foreign  bodies  in  the  238 

Extraction  of  teeth,  a  local  anaesthetic  for  238 

Facial  erysipelas,  237 

Follicular  tonsillitis,  98 

Grippe,  benzoate  of  soda  in  57 

Incompatibility  of  calomel  with  chlorides,  acids  and  albuminoids  273 

Itch,  balsam  of  Peru  in  57 

Laryngismus  stridulous,  124 

Measles,   123 

Middle  ear,  function  of  98 

Otitis  in  scarlatina,  to  avoid  25 

Prgenancy,  drugs  which  may  or  may  not  be  prescribed  during  237 

Prof.  Newman's  caution,  59 

Urticaria,  9 
Tide  water  medical  association,  61 
Timely  suggestions,  309 
Time  of  meeting,  59 
Tobacco  habit  as  a  cause  of  disease,   345 

on  the  sight,  the  action  of  460 
Took  his  own  physic,  98 
Toothache  remedies,  241 
Trachea,  a  shawi  pin  in  the  409 
Treatment  of  diseases,  49 
Tuba!  pregnancy,  ruptured  235 

Tuberculosis,  a  few  suggestions  on  prevention  of  366 
Tuberculous  bone  disease,  surgical  treatment  of  199 
Two  curious  freaks,  204 
Typhoid  fever  and  its  treatment,  209 
some  thoughts  about  436 
surgery  of  85 
surgical  intervention  in  perforating  peritonitis  from  232 

Universal  Medical  Journal,  133 


University  of  California  and  Hahnemanu  College,  60 

of  Virginia,  459 
Uterine  appendages,  conservative  surgery  of  the  197 

Ventral  suspension  of  the  uterus  for  fixed  retroflexion,  112 

Veratrum  viride  with  especial  reference  to  its  therapeutic  uses  in  serous  and 

parenchymatous  inflammations,  396 
Von  Reypon,  Surgeon  general  315 

Weiner,  Dr.  Morris  98 
Western  newspaper,  a  201 
Whooping  cough,  citric  acid  in  460 
Wilson,  Dr.  A.  R.  66 
Women  doctors,  275 
Woodley,  Dr.  Wm.  T.  429 

X-ray  in  its  medico-legal  aspects,  84 

Yellow  fever,  the  serum  diagnosis  of  118 
to  guard  against  430 
at  McHenry,  Miss.  458 


T\venty-Fir«t  Year. 


JANUARY  5,  1898. 


'^^^! 


Vol.  ii.    NO.  1. 


NORTH  CAROLINA 

MEDICAL  JOURNAL 

PUBLISHfeD  feEMI^MON^tHL^Y  A¥;?2:oo  PEl^  AKNUtt. 


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SANMETTO 


F-OR 


GENITOURINARY  DISEASES. 


A  Scientific  Blending  of  TrueSantal  aod  SawPalniefto  In  a  Pleasant  Aromatic  Vehicle. 
A  Vitalizing  Tonic  to  the  Reproductive  System. 

SPECIALLY  VALUABLE  IN 

PROSTATIC  TROUBLES  OF  OLD  MEN-IRRITABLE  BLADDER- 

CYSTITIS-URETHRITIS-PRE-SENILITY. 

DOSE:-On«  Taaspoonful  Four  Titan  t  Day.  OD  CH  EM .  CO. ,  N  EW  YORK. 


BELLEVUE  HOSPITAL  MEDIOAL  COLLEGE, 

CITY  OF  NEW  YORK. 
SESSIOIjT'S    OIH'    18Q8-0Q- 

TnK  RsecLAB  Session  begins  on  Monday,  October  3, 1698,  and  continues  for  tthirty-two  weeks.  For  first-year 
and  second-year  students,  attendance  on  four  courses  of  lectures  is  requii-ed  for  graduation.  Third-year  stu- 
dents are  admitted  under  the  tbree-ycar's  system. 

Graduates  of  other  accredited  Medical  Colleges  are  admitted  as  third-year  students.  Students  who  have  at- 
tended one  full  regular  course  of  lectures  at  another  accredited  Medical  College  are  admitted  as  seoond-year 
students  without  examination.  Students  are  admitted  to  advanced  standing  for  the  second  or  third  years, 
either  on  approved  credentials  from  other  accredited  Medical  Colleges  or  after  examination  on  the  subjects 
embraced  in  the  curriculum  of  this  College. 

The  annual  circular  for  1898-9,  giving  full  details  of  the  curriculum  for  the  four  years,  the  Regents'  reqiiire- 
ments  for  matriculation,  requirements  for  graduation  and  other  information,  will  be  published  in  June,  1898- 
Address  Austin  Flint,  Secretary,  Bellevue  Hosptal  Medical  College,  26th  Street,  and  First  Avenue,  New  York 
City. 

Ttie  lsra,tione,l  Oollege 

OIF* — 

ELEOTEO-THER  A_PEXJTICS. 

The  only  College  in  the  United  States  devoted  exclusively  to  Electro-Therapeutics,  Teu  Instructors.  A 
thorough  practical  COURSE  of  INSTRUCTION  by  MAIL  to  those  who  cannot  come  here.  Diplomas  granted 
when  competent.    Degree  conferred.    Write  for  announcement. 

168  BELLEFONTAINE  STREET,  INDIANAPOLIS  IND, 


NORTH  CAROLINA 

MEDICAL  JOURNAL. 

A  SEMI-MONTHLY  JOURNAL  OF  MEDICINE  AND 
_^ SURGERY. 

Vol.  XLIj^  Wilmington,   January  5,    1898.  No.    i. 

©rtoinal  Communications. 


THE  USE  OF  THE  SHARP  CURETTE  IN  SEPTIC 
INFECTION  AFTER  LABOR  AND  ABORTION.* 

By  J.   NoER,   M.D.,   Stoughlon,  Wis. 


THE  judicious  use  of  the   sharp  curette  in   sepsis  following 
labor  and  abortion  is  a  simple  and  safe  surgical  opera- 
tion too  often  neglected   and   unreasonably  opposed   by 
the  general  practitioner. 

Curettage  of  the  uterus  will  be  dangerous  and  disastrous,  or 
safe  and  efficient  in  exact  accord  with  the  skill,  good  judgment 
and  clinical  insight  of  the  operator. 

At  the  outset  let  us  note  what  are  the  local  and  general  con* 
ditions  likely  to  be  presented  in  a  case  of  puerperal  sepsis. 
We  can  divide  septic  infective  processes  that  occur  after  labor 
into  two  classes,  namely,  cases  where  the  toxaemia  is  dependent 
upon  an  invasion  of  the  blood  itself  and  manifesting  no  marked 
local  lesions,  and  cases  where  the  infeetion  is  primarily  local 
and  is  propagated  from  the  local  focus  to  distant  parts  by  con- 
tinuity of  surface  or  through  the  lymphatics.  All  our  cases 
can  be  conveniently  considered  in  this  way.  Auto-infection  is 
so  doubtful  and  rare  as  to  be  practically  out  of  consideration. 
Ninety-nine  per  cent,  of  all  cases  of  puerperal  iepsis  originate 
at  some  point  in  the  genital  tract.     It  is  therefore  important  to 

*Read  before  the  State  Medical  Society  of  Wisconsin,  May  1897. 


NOER.-SEPTIC  INFECTION  ETC. 

trace,    if  possible,    the   starting  point  of  the   sepsis   by  a  most 
thorough  physical  examination. 

Having  located  the  source  of  the  sepsis  the  treatment  to  be 
applied  will  not  materially  differ  from  that  which  is  applied  in 
sepsis  in  other  parts  of  the  body. 

Why  intelligent  practitioners  are  so  often  satisfied  to  let  a 
case  of  peurperal  sepsis,  which  might,  by  the  application  of  the 
most  simple  surgical  procedure,  establish  speedy  convalesence, 
go  on  under  the  delusive  treatment  of  quinine,  opium  and  the 
vaginal  douche  is  a  mystery.  It  is  possible  that  we  are  too 
often  afraid  of  interfering  with  nature's  process  of  destruction, 
or  that  we  are  in  doubt  about  diagnosis  or  that  we  have  not 
kept  abreast  of  the  times. 

We  are  called  to  see  the  case,  we  will  say,  on  the  third  to  the 
fifth  day  after  labor.  We  are  ignorant  of  the  conditions  and 
the  technique  practised  during  confinement,  that  is,  whetherit 
was  aseptic  or  not,  and  we  cannot  tell  whether  everything  that 
ought  to  come  away  has  been  removed.  There  is  elevation  of 
temperature  and  pulse,  the  lochia  are  more  or  less  offensive, 
there  are  pain  and  tenderness  over  the  uterus.  What  are  we  to 
do  under  these  circumstances?  We  cleanse  the  external  geni- 
tals, administer  an  antiseptic  vaginal  douche,  empty  the  bowels^ 
and  put  the  patient  on  quinine,  and  possibly  opium.  We  re- 
turn in  from  twelve  to  twenty-four  hours  and  find  our  patient 
improved  or  convalescent.  Under  these  conditions  we  are  sat- 
isfied to  let  well  enough  alone. 

But  suppose  that,  on  the  other  hand,  instead  of  improvement 
there  is  an  aggravation  of  all  the  symptoms,  indicating  that 
there  is  an  extension  of  the  infection  or  that  we  have  not  reached 
the  seat  of  the  trouble.  Should  the  above  treatment  be  con- 
tinued? I  think  not.  A  thorough  physical  exploration  will  be 
necessary.  We  administer  an  antiseptic  douche,  place  the  pa- 
tient in  Sim's  position,  introduce  the  speculum  and  proceed  to 
ascertain  the  exact  local  conditions.  We  find  in  this  case  upon 
inspection  that  the  lochia  has  been  changed  to  a  muco-purulent 
discharge  indicating  infection  of  the  uterine  cavity.  The  mi- 
croscope will  demonstrate  whether  it  is  a  simple  infection  by 
pus  microbes  or  whether  it  is  due  to  specific  germs  as  diptheria, 
gonorrhoea,  etc.  If  the  infection  is  speciffc,  there  can  be  no 
doubt  about  the  utility  of  a   thorough  curettage  of  th^  entire 


NOEK.— SEPTIC  INFECTION  ETC  - 

Uterine  endometrium,  followed  by  hot  antiseptic  irrigation,  and 
the  application  of  tincture  of  iodine,  or  a  solution  of  chloride 
of  zinc  (20^)  and  packing  with  iodoform  gauze. 

If,  however,  the  infection  is  nonspecific,  which  will  be  the 
case  in  most  instances,  the  choice  of  action  will  lie  between 
antiseptic  uterine  irrigation  alone,  or  irrigation  with  curettage. 
If  we  have  reason  to  believe  that  parts  of  the  placenta  or  secun- 
dines  have  been  retained,  we  ought  to  curette,  irrigate  with  1 
per  cent,  lysol  or  creoline,  and  drain  with  iodoform  gauze.  If 
there  is  no  retention  of  membranes  or  placenta;  intrauterine 
irrigation  with  i  per  cent,  lysol  or  creolin  solution  may  be  suffi- 
cient, provided  however,  that  the  infective  germs  have  not  pen- 
etrated too  deeply  into  the  uterine  tissues.  In  the  latter  event 
curettage  would  appear  to  be  rational  treatment. 

To  state  that  all  placental  remains  and  dead  tissue  should  be 
removed  in  all  cases  after  labor  and  abortion  is  a  mere  truism 
The  difficulty  is  to  ascertain  when  these  things  have  been  re- 
tained. We  are  dealing  with  a  dark  cavity  that  is,  under  the 
circumstances,  difficult  to  explore  and  very  easy  to  infect,  pro- 
vided we  are  not  scrupulously  cai-eful  as  regards  the  practise  of 
antiseptic  technique.  In  the  puerperium  there  will  be  compar- 
atively few  cases  that  require  curettage  while  the  reverse  will  be 
true  in  cases  of  abortion. 

The  indications  for  the  use  of  the  curette  are  given  by  a  re- 
cent authority  as  follows:  (1)  In  cases  of  incomplete  abortion 
when  portions  of  the  ovum  or  placenta  are  retained,  that  can- 
not be  removed  by  means  of  the  finger  or  ovum  forceps;  and 
(2)  in  the  puerperium  when  septic  symptoms  have  appeared, 
which  are  probably  attributable  to  decomposition  of  pieces  of 
placenta  or  membranes  in  the  uterine  cavity.* 

There  can  be  no  doubt  about  the  clearness  and  the  correct- 
ness of  these  indications  and  there  ought  not  to  be,  in  the  ma- 
jority of  cases,  much  difficulty  in  their  recognition.  In  cases 
of  abortion  we  ought  never  to  await  the  orset  of  septic  symp- 
toms but  curette  at  once  if  there  are  evidences  of  retained  pla- 
centa or  membranes.  The  use  of  the  finger  is,  however,  under 
the  circumstances  a  procedure  that  is  likely  to  be  futile  in  most 
cases.  It  is  impossible  to  explore  the  ucerine  cavity  with  the 
finger  without  pressing  down  the  fundus  of  the  uterus  and  in- 
*J.  C.  Cameron  American  text-book  on  Obstetrics,  page  872. 


NOER.— SEPTIC  INFECTION,  ETC. 
4 

troducing  the  hand  into  the  vagina,  a  procedure  that  is  likely 
under  existing  conditions,  not  to  be  tolerated  by  the  patient, 
certainly  not  more  than  once,  without  an  anaesthetic. 

The  placenta  forceps,  highly  commended  by  many  obstetri- 
cians, *has  in  my  hands  been  unsatisfactory  except  for  the  pur- 
pose of  breaking  up  and  removing  loose  placental  masses  from 
within  the  uterus.  In  adherent  placenta  it  is  very  difficult  to 
tell  whether  the  forceps  grasps  placental  remains  or  the  softened 
uterine  walls.  In  any  event  the  forceps  removes  only  patches 
here  and  there,  leaving  interspaces  of  infectious  material  which 
must  be  removed  by  the  curette  or  remain  to  propagate  the 
sepsis. 

The  sharp  curette  should  be  used  only  with  the  greatest  care 
and  under  the  most  rigid  antiseptic  regimen.  If  curettage  is 
done  only  bunglingly  and  with  little  attention  to  the  details  of 
surgical  cleanliness  during  and  after  the  operation,  it  would  be 
better  for  the  surgeon  and  certainly  safer  for  the  patient  to 
leave  the  case  to  nature.  An  incomplete  removal  of  dead  septic 
material  from  the  uterus  with  the  sharp  curette  can  do  little 
good  and  much  harm.  Such  an  operation  can  only  open  new 
avenues  for  infection  and  make  nature's  work  more  difficult. 
On  the  other  hand  if  the  rules  of  antisepsis  be  neglected  we  are 
not  likely  to  improve  the  condition  by  curettage.  This  holds 
true  not  only  during  the  operation  but  also  at  the  subsequent 
change  of  dressings,  when  it  is  very  easy  to  reinfect  the  patient 
through  the  denuded  uterine  surface. 

As  a  general  practitioner  I  have  encountered  a  number  of 
difficulties  in  carrying  out  the  technique  and  applying  curettage 
in  practice.  Where  a  patient  is  at  a  distance  from  the  physi- 
cian and  without  the  aid  of  a  trained  or  intelligent  nurse  it  is 
often  impossible  to  undertake  the  operation  even  when  indica- 
tions are  imperative. 

Among  the  difficulties  encountered  after  the  operation  are  (t) 
pain  and  discomfort  from  the  tampon,  (2)difficulty  in  getting  the 
bladder  emptied  by  reason  of  an  incompetent  nurse,  (3)  diffi- 
culty in  getting  people  to  understand  the  importance  of  clean- 
liness and  asepsis  Keeping  in  mind  the  indications  for  the 
operation  and  the  results  to  be  obtained  it  is  possible  to  obviate 
to  some  extent  these  difficulties.  If  we  are  called  early  and 
*Longyear,  International  Clinics,  4th  Series  Vol.  11,  page  283. 


GRAHAM, -PUERPERAL  INFECTION.  - 

can  recognize  the  case  that  requires  curettage  we  need  apply  the 
sharp  instrument  only  to  the  portion  of  the  endometrium  where 
there  is  placental  or  other  dead  tissue.  The  sensation  conveyed 
to  the  hand  and  the  sound  produced  by  the  curette  will  give  us 
an  idea  where  to  apply  and  how  long  to  continue  scraping. 

The  rest  of  the  endometrium  may  then  be  scraped  with  a 
dulled  racamier,  thorough  antiseptic  irrigation  practiced,  fol- 
lowed by  the  introduction  of  an  iodoform  suppository  and  an 
iodoform  gauze  rope  for  drainage.  The  upper  vagina  should 
be  packed  with  iodoform  gauze,  the  outer  portion  with  absorbent 
cotton  and  a  T  bandage  applied. 

If  our  tampon  is  rather  loose  there  will  be  no  pain  and  the 
urine  can  be  voided  bj  turning  the  patient  prone  and  pressing 
tampon  with  fingers  upwards  and  backwards.  I  have  had  no 
difficulty  after  the  adoption  of  this  procedure  in  a  number  of 
recent  cases.  We  must,  however,  look  very  sharply  for  symp- 
toms of  iodoform  poisoning. 


PUERPERAL  INFECTION. 
By  St.  Joseph  B.   Graham,  M.D.,  Savannah,  Ga, 


IF  this  paper  were  exhaustively  written  it  would  consume  more 
time  than  can  just  at  present  be  given  in  writing  it,  and 
more  than  you  can  perhaps  afford  in  listening  to  it  when 
read.  Therefore,  an  attempt  only  is  made  to  touch  upon  what 
we  consider  the  most  important  under  the  scope  of  the  paper. 

The  causes  of  puerperal  infection  aie  various  and  can  be 
classified  as  follows:  Infection  from  streptococcus  pyogenes, 
usual  cause;  staphylococcus  pyogenes  aureus  and  albus;  Klebs- 
Loeffler  bacillus  of  diphtheria;  bacillus  coli  communis;  Gono- 
cocus  of  Niesser  of  gonorrhoea,  and  perhaps  the  bacillus  of 
malignant  oedema  (vibrion  septique  Pasteur). 

The  manner  or  way  of  introduction  of  the  micro-organisms 
is  two-fold:  either  from  the  patients  themselves  or  their  dress- 
ings, or,  the  most  usual,  from  the  hands  instruments  or  dress- 
ings of  the  physician  or  nurse. 


g  GRAUxVM.-PUEKPERAL  INFECTION. 

It  seems  quite  out  of  place  to  discuss  at  length  all  of  these 
wellknown  sources. 

The  heading  infection  from  patients  themselves  might  be 
further  elaborated  by  mention  of  the  role  played  by  the  birth 
of  dead  and  macerated  foeti,  retained  placenta,  in  part  or  whole 
accessory  growths  of  the  placenta,  and  spurious  placenta,  all 
of  which  favors  infection  by  furnishing  a  favorable  soil  for  the 
growth  and  multiplication  of  micro-organisms. 

It  is  plain  that  in  order  to  have  puerperal  infection  certain  of 
these  lower  organisms  must  be  present,  and  they  gain  admission 
either  through  a  solution  of  continuity,  small  or  large,  or 
through  the  puerperal  endometrium.  The  virulence  of  these 
organisms  varies  much,  due  to  differences  in  temperature, 
source  and  growth,  and  the  infection  varies  with  this  condition, 
as  well  as  with  the  number  of  microbes  present,  and  the  indi- 
vidual susceptibility  of  the  patient. 

The  pathology  of  puerperal  infection  depends  upon  the  species 
of  organism  producing  the  infection.  In  ordinary  cases  the  in- 
fection is  due  to  the  streptococcus  pyogenes,  and  the  most 
easily  noted  change  is  that  of  the  blood  even  before  and  espe- 
cially after  death.  It  is  thick  and  black,  is  acid  in  reaction,  and 
decomposes  quickly.  Streptococci  are  found  in  it  at  times  in 
large  numbers,  as  well  as  in  other  organs  and  tissues  of  the 
body.  The  leucocytes  and  red  corpuscles  are  disintegrated, 
partly  by  the  organisms  themselves,  as  well  as  by  the  toxine 
elaborated  by  them.  In  consequence  of  this  change  in  the 
blood  and  in  the  blood  vessels,  numerous  hemorrhagic  foci  take 
place  in  the  internal  organs.  In  the  intestines  we  may  find 
enteritis  or  ileo-colitis,  in  the  heart  pericarditis,  endo-carditis, 
in  the  kidneys  an  acute  inflammatory  catarrhal  condition,  in 
the  uterus  metritis,  in  the  veins  plebitis.  Changes  in  the  in- 
ternal organs  are  not,  however,  constant.  When  the  infection  is 
a  mixed  one,  we  have  a  pyemic  condition  combined  with  it 
where  metastatic  abscesses  are  present  through  the  different 
tissues  and  organs  of  the  body. 

Through  microscope  No.  i,  you  will  see  a  section  made  from 
the  broad  ligament  after  death  containing  numerrus  staphy- 
lococci. In  No.  2,  you  will  see  section  of  the  heart  muscle  con- 
taining streptococci. 

Both  of  these  were  prepared  by  the  author. 


GRAHAM.-PUEEPERAL  INFECTION.  7 

TREATMENT. 

Of  first  and  greatest  importance  is  the  preventative  treat- 
ment— its  causes  usually  being  under  our  control.  We  must 
begin  prophylaxis  when  we  can  see  any  indication  for  the  same 
at  any  time  before  the  period  of  labor.  Any  condition  or  dis- 
ease, local  or  constitutional,  that  lowers  the  vitality  of  the 
patient  or  furnishes  a  nidus  for  bacteria  certainly  predisposes 
fo  infection,  and  we  may  include  auto-intoxication  in  the  list. 
These  should  be  met  by  proper  therapeutic,  surgical  and  hygienic 
measures  and  if  possible  relieved  or  cured. 

Any  abnormal  secretion  from  the  vagina  calls  for  proper 
treatment  as  soon  as  recognized. 

We  often  find  a  leucorrhea  due  solely  to  systemic  disturbance, 
which  resists  of  course  local  treatment,  but  is  readily  cured 
when  the  real  cause  is  recognized.  In  chronic  malarial  toxaemia 
the  author  has  often  seen  this  condition,  which  readily  yields  to 
proper  doses  of  iron,  quinine  and  arsenic. 

Of  course  if  gonorrhoea  (recognized  by  gonococci)  is  present 
treatment  will  at  once  be  resorted  to.  In  health  the  vagina 
secretes  a  mucous  and  cultivates  saphrophytic  baccilli,  which 
render  it  immune  to  the  invasion  and  harmful  influences  of 
pathogenic  bacteria;  therefore,  in  health  preliminary  antiseptic 
douches  are  not  only  uncalled  for  but  are  harmful,  in  that  they 
upset  or  destroy  the  provisions  of  nature. 

As  an  antiseptic  for  the  hands  the  writer  prefers  a  2  or  3  per 
cent,  solution  of  formalin(a  40  per  cent,  solution  of  formalde- 
hyde) gained  by  the  incomplete  oxidation  of  methylalcoho^  dis- 
solved in  water.  The  nails  are  first  well  cleaned  (to  prevent 
what  a  witty  friend  a  few  days  ago  remarked,  making  cultures 
from  the  finger  nails  before  visiting  the  case  to  decide  what 
kind  of  serum  to  use).  No  matter  how  clean  they  may  appear, 
a  new  or  sterilized  nail  brush  and  sand  soap  is  used  for  the 
fingers,  hands  and  arms,  afterwards  washed  in  alcohol  and 
thoroughly  washed  and  soaked  in  the  formalin  solution.  It  is 
needless  to  say  that  nothing  unsterilized  should  be  touched 
after  the  cleansing.  A  sterilized  gown  should  be  worn  by  phy- 
sician and  nurse.  Everything  should  be  gotten  in  readiness 
beforehand  and  the  writer  begs  to  show  you  here  a  little  sterili- 
zer for  instruments  when  needed,   of  his  own   evolution,    which 


3  GRAHAM.-PUERPERAL  INFECTION. 

is  compact,  cheap,  easy  to  transport  and  fulfills  the  purpose  for 
which  it  is  intended.  With  the  small  alcohol  stoves  the  water 
will  be  boiling  in  five  minutes;  a  2  per  cent,  soda  solution  may 
be  used  and  formalin  may  be  added  if  desired.  Make  as  few 
vaginal  examinations  as  possible  and  wash  the  hands  in  forma- 
lin solution  after  each  examination,  and  when  a  lubricant  is 
needed  use  sterilized  cotton  seed  oil  or  vaseline. 

The  writer  had  the  good  fortune  to  serve  a  few  years  in  the 
frontier  service  as  physician,  being  at  a  post  among  the  Sioux 
Indians,  and  there  noted  the  extreme  rarity  of  puerperal  infec- 
tion among  them,  despite  the  filth  and  unhygienic  condition  of 
the  surroundings  of  puerperal  women.  They  never  permit  the 
introduction  of  the  finger  for  examination  or  the  hand  for  aid, 
except  in  the  most  extreme  cases,  and  these  cases  were  of  such 
a  nature  that  death  frequently  came  before  delivery.  In  the 
few  cases  of  infection  the  wausecapejutawicasa  (the  white  med- 
icine man)  had  been  in  attendance. 

The  patient's  external  genitals  should  be  thoroughly  scrubbed. 
Most  of  our  patients  do  not  neglect  their  body  bath.  Where 
they  do  it  is  well  to  remind  them  of  its  usefulness,  aside  from 
common  cleanliness.  The  woman  in  and  after  labor  should  be 
treated  with  the  same  regard  for  ascepticism  and  surgical  clean- 
liness as  we  would  use  in  the  most  extensive  operation  wound 
of  our  own  making,  where  the  surface  was  previously  free  from 
infection. 

Unless  the  hands  have  been  in  the  uterus,  which  is  to  be 
avoided  if  possible,  by  Crede's  method  of  expression,  or  there 
is  some  indication  for  its  use,  the  writer  would  not  resort  to 
intra-uterine  douches.  When  labor  and  the  soft  parts  are  nor- 
mal and  the  rules  of  ascepticism  have  been  rigidly  adhered  to, 
vaginal  douches  can  do  no  good. 

The  treatment  of  infection  should  be  local  and  constitutional, 
surgical  and  medical,  influenced  of  course  by  the  variety  of 
micro-organisms  producing  the  condition.  The  parts  should 
be  examined  as  far  as  possible  by  the  eye  to  determine  the  focus 
and  in  a  measure  the  classification  of  infection,  and  upon  the 
information  gained  the  treatment  will  depend.  For  local  disin- 
fection the  writer  prefers  a  i  to  4  per  cent,  solution  of  formalin 
10  any  other  antiseptic  known.  Where  the  point  of  infection  is 
in  the  uterus  it  must  be  decided  whether  it  is  saprsemic  or  sep- 


GRAHAM.— PUERPERAL  INFECTION.  g 

ticemic.  Clearing  and  cleaning  out  is  indicated  ;  the  surgically- 
clean  finger,  dull  curette  or  sharp  curette  may  be  used  (each  has 
its  advocates  and  disadvantages,)  followed  by  prolonged  douch- 
ing with  or  without  active  germicidal  agents.  Here  again  the 
writer  prefers  formalin  solution.  It  is  non-toxic,  but  very 
slightly  irritating  in  proper  strength,  and  as  far  as  germicidal 
properties  are  concerned  heads  the  list. 

If  remains  of  necrosed  tissue  are  not  present  curetting  will 
accomplish  nothing. 

If  the  case  is  seen  early,  before  septic  absorption  and  migra- 
tion of  bacteria  has  taken  place  to  any  very  great  exsent,  the 
writer  prefers  to  use  a  blunt  dilator  and  irrigator  combined, 
which  I  here  beg  to  present  to  you.  This,  after  sterilization,  is 
introduced  and  opened,  the  irrigating  portion  having  been  filled 
with  liquid  to  prevent  the  introduction  of  air.  It  is  attached 
to  an  irrigating  bottle  or  funnel  and  a  solution  of  formalin 
allowed  to  flow  in,  while  the  dilator  is  moved  in  every  possible 
direction.  This  may  be  maintained  as  long  as  desired,  being 
careful  not  to  have  the  solution  too  strong  and  the  hydrostatic 
pressure  too  great  by  loo  high  an  elevation  of  the  container. 
The  temperature  afterwards  should  be  the  guide  as  to  the  length 
of  time  and  value  of  the  washing  out.  Formaldehyde  or  iodo- 
form gauze  may  be  used  to  induce  drainage  and  act  as  germi- 
cidal agents,  or  as  iodoform  does  to  prevent  the  formation  of 
toxines.  An  original  plan  has  presented  itself  to  the  writer, 
but  which  an  opportunity  has  not  offered  for  use.  It  is  the  con- 
veying of  formaldeh)^de  gas  combined  with  vapor  of  alcohol  into 
the  uterine  cavity  through  a  suitable  tube  uterine  applicator. 
Theoretically,  it  should  prove  of  great  value;  practically,  we  do 
not  know  what  it  will  do.  At  any  rate  it  is  non-toxic  to  the 
patient.  Steam  at  loo  to  115C.  has  been  used  in  this  manner 
with  reported  good  results. 

The  consticutional  treatment  is  modified  in  a  measure  by  the 
kind  of  infection   present. 

If  diphtheritic,  due  to  Klebs-Loifier  bacilli,  anti-diphtheria 
serum  should  be  used.  If,  as  more  often  happens,  the  pseudo- 
membranous angina  and  the  poisoning  is  due  to  streptococcus 
pyogenes,  antistreptococcus  serum  is  indicated,  that  of  Mar- 
morek  probably  being  the  most  noted,  but  many  serums  made 
in  our  own  country  are  as  good. 


J  Q  SOCIETY  REPORTS. 

Ten  cases  are  reported  of  streptococcus  phlegmon  where  the 
swelling  of  lymphangitis  and  lymphadenitis  quickly  disappeared 
after  the  use  of  serum.*  The  serum  treatment,  however,  seems 
not  to  have  yet  reached  that  high  grade  of  healing  power  to 
which  it  is  thought  and  hoped  it  will  later  rise. 

The  indications  are  to  sustain  by  proper  remedial  agents  and 
stimulants,  judiciously  employed,  the  patient's  vitality  until  the 
vis  medicatrix  naturae  sufficiently  asserts  itself.  The  writer  be- 
lieves in  pushing  alcoholic  stimulants. 

With  the  report  of  one  case  I  beg  to  close  my  too  brief  re- 
marks. Patient,  age  39,  delivered  at  full  time  of  twins,  dead 
three  or  four  weeks  in  utero,  and  attached  to  one  placenta, 
which  came  away  entire;  no  lacetation  of  uterus  or  soft  parts. 
Next  day  lochia  apparently  normal.  On  fourth  day,  at  6  a.m., 
severe  chill,  followed  by  temperature  of  105,  pulse  148,  stupor. 
Used  dilator  as  above  described  and  irrigated  with  formalin  so- 
lution for  one  hour.  A  few  small  shreds  came  away,  but  noth- 
ing else.  Temperature  sank  to  103  in  the  afternoon,  when  irri- 
gation was  again  resorted  to.  Temperature  at  9  p.m.  102.  Irri- 
gation again  next  day;  temperature  102,  in  afternoon  loi;  irri- 
gation. Temperature  at  y  p.m.,  100.  Morning,  irrigation; 
temperature  xoo^;  afternoon  temperature  ioo|,  irrigation ;  night 
temperature  normal.  Irrigation  next  morning.  Patient  bright, 
appetite  returning  and  went  on  to  recovery. 

Blood  examination  showed  no  plasmodia  but  excess  of  leuco- 
cytes.   Calomel  in  small  doses  and  quinine  were  given  internally. 


Society  15?cport0« 


RALEIGH  ACADEMY  OF  MEDICINE. 

STATED    MEETING    AUGUST    4th,     1897, 

K.    P.   Battle,   Jr.,   M.D.,  President,   in  the  Chair. 


DISCUSSION  of  subject: 
"can  typhoid  fever  be  aborted?" 
Dr.  A.    IV.   Knox,    in   opening  the  discussion,    regretted 
that  from   lack   of  time  he  had   not   tabulated  his  cases 


SOCIETY  EEPORTS.  j  j 

treated  by  the  Woodbridge  method.  Since  May  1896,  he  had 
employed  his  treatment  in  16  cases  with  3  deaths.  In  all  of 
these  the  temperature  had  reached  normal  in  'j'^/o.  days  as  an 
average,  the  fatal  cases  being  due  to  complications  and  other 
circumstances  which  will  be  referred  to.  From  this  he  is  forced 
to  conclude  that  typhoid  fever  can  be  aborted  and  that  in  the 
Woodbridge  method  we  have  a  means  of  aborting  it.  In  re- 
sponse to  a  question,  "How  long  did  the  temperature  stay  down 
after  coming  to  the  normal?"  Dr.  Knox  stated  that  in  all  but 
three  or  four  of  the  cases  the  fever  returned  but  never  reached 
its  former  height  and  the  patients  were  always  comfortable. 
In  the  first  case  which  he  treated  according  to  this  plan,  the 
cause  of  a  slight  rise  of  temperature  was  found  to  be  non-ab- 
sorption of  the  tablets  and  capsules;  under  calomel  and  salines 
these  were  found  in  the  dejections  and  the  fever  came  dov/n. 
The  speaker  thought  it  behooved  us  all  to  examine  into,  to 
study  and  to  use  the  Woodbridge  method.  The  bath,  accord- 
ing to  Brand,  had  been  the  best  treatment  before  Dr.  Woo'd- 
bridge  introduced  his  plan.  By  the  Brand  method  the  mortal- 
ity had  been  reduced  from  about  21  per  cent,  to  7  per  cent. 
Woodbridge  has  just  reported  over  8,000  cases  with  a  death-rate 
of  less  than  2  percent!  Dr.  Knox's  own  conviction  was  that 
typhoid  fever  could  be  aborted. 

Br.  W.  I.  Royster. — The  Brand  method  of  treating  typhoid 
fever  was  the  greatest  advance  made  in  the  management  of  that 
disease,  greater  even  than  many  of  the  achievements  of  modern 
surgery.  It  reduced  the  mortality,  rendered  the  patient  com- 
fortable, did  away  with  many  of  classical  symptoms — but  J 
not  apparently  shorten  its  course.  The  treatment  by  elimina- 
tion and  antisepsis  (as  advocated  by  Thistle  and  others)  has,  in 
his  opinion,  succeeded  just  as  well  and  is  more  conveniently 
carried  out.  There  is  more  in  typhoid  fever  than  the  fever,  and 
the  typhoid  toxines  in  Peyer's  patches,  liver,  spleen  and  mesen- 
teric glands,  are  not  the  only  causes  of  the  high  temperature 
with  its  concurrent  symptoms.  The  absorption  of  poisons  from 
the  intestinal  canal  is  one  of  the  factors  in  causing  the  fever, 
and  by  the  eliminative  and  antiseptic  treatment  this  is  reduced 
to  a  minimum.  The  Woodbridge  method  he  had  absolutely  re- 
pudiated, chiefly  on  the  ground  that  no  combination  of  drugs 
in  fixed  doses  can  be  suitably  administered  over  a  continuous 


SOCIETY  REPOKTS. 
12 

period  to  every  patient  suffering  from   typhoid   fever.      He  had 
treated  two  cases  according  to  Woodbridge — both  children,   in 
whom  typhoid  often  runs  a  mild  course,  sometimes  of  less  than 
two  weeks'  duration.      In  one  of  the   cases   there  was  produced 
hypercatharsis  and  the  treatment  had  to  be  discontinued;  in  the 
other,  it  seemed  to  act  no  better  than  the  eliminative  and  anti- 
septic plan.      He  had  seen  two  of  Dr.  Knox's  cases   with  him. 
The  principle  of  the  Woodbridge  method  is  good — freft   move- 
ment of  the  bowels,  opening  up   the   glandular  secretions  and 
getting  the  patient's  skin  in  good  condition.      For  the  last  three 
years  he  has  used  the  eliminative  and    antiseptic   method,  con- 
sisting for   the   most   part  of  giving  (a)  calomel  in  one-quarter 
grain  doses  every  hour,  followed  by  salines,  to  secure  from  four 
to  six,  or  even  more,  free  evacuations  in  twenty-four  hours,   re- 
gardless of  the  number  of  doses,  and  (b)  the  internal  adminis- 
tration  of  some  intestinal  antiseptic   (generally  carbonate    of 
guaiacol).      He  did  not  remember  the  number  of  cases,  but  had 
five  during  one  week  last  summer,  all  recovering  nicely.    There 
is  no  doubt  that  securing  free  movements  of  the   bowels  is  the 
keynote   in   treating  typhoid.      He    feels  more   comfortable   in 
attacking  a  case  of  typhoid  fever  now  than  formerly.      The  fol- 
lowing he  considered  the  best  treatment:     Proper  feeding,  iree 
elimination,  intestinal  antisepsis  and  cool   sponging.      Food  is 
very  important.      He  gives  less  than   he  used  to   and  finds   that 
patients  can  get  along  on  very  little.     Milk  he  regarded  as  the 
worst   possible    form  of  food    in   most  cases.      It  is   not  easily 
digested;  it  ferments  in   the  bowels,  producing  foul  discharges; 
and  it  is  not  always  retained  by  the  stomach.     Various   substi- 
tutes— peptonoids,   panopepton,    chicken   broth,   etc., — are  fre- 
quently   needed.      The  drinking   of    large   quantities  of  water 
(preferably  boiled)   is  one  of  the  elements  of  success.      Some 
physicians  have  even  gone  so  far  as  to  give  no  food  at  all,  but 
to  make  their  patients  drink   a   gallon   or  more  of  water  in  the 
day. 

Dr.  James  McKce  considered  typhoid  fever  an  acute  self- 
limited  disease,  tending  to  recovery,  the  limit  running  from  two 
weeks  to  two  or  three  months,  according  to  the  type.  He  had 
seen  some  of  Dr.  Knox's  cases  last  summer  and  was  impressed 
with  their  treatment,  but  he  must  adhere  to  his  grounded  prin- 
ciples— self-limitation  and  not  cured  by  medicine.     All  the  re- 


SOCIETY  REPORTS  I  3 

ports  of  Dr.  Woodbridge,  up  to  this  year,  were  from  the  West. 
Dr.  McKee's  method:  Cold  water  internally  and  plenty  of  it; 
externally,  likes  a  cold  pack  in  the  form  of  a  cloth  extending 
from  shoulders  to  pubes  in  front  and  changed  frequently ;  never 
stops  a  diarrhoea,  because  he  believes  in  elimination.  There 
are  many  varieties  and  types  of  typhoid  fever.  He  believes  it 
cannot  be  aborted,  any  more  than  measles  or  scarlet  fever  can 
be  cut  short. 

Dr.  P.  E.  Hines  said  that,  if  he  understood  it  correctly,  the 
word  "abort"  means  to  cut  short.  Granting  that,  he  did  not 
believe  that  typhoid  fever  could  be  aborted.  Ever  since  he 
began  treating  typhoid  he  had  been  satisfied  with  his  results. 
He  had  not  lost  a  single  c  .se,  save  those  who  died  from  hemor- 
rhage, those  (some  5  or  6)  who  had  entered  the  hospitals  mori- 
bund, and  one  who  got  up  against  orders,  walked  across  the 
room  and  fell  dead.  He  has  not  treated  and  does  not  now  treat 
any  cases  exactly  alike.  He  keeps  the  patient  clean,  gives  him 
milk  diluted,  keeps  the  bowels  moderately  open,  and  uses  a 
mild  antipyretic  or  the  sponge  or  tub  bath,  according  to  cir- 
cumstances. He  had  always  sponged  his  cases,  before  the 
Brand  method  was  thought  of.  He  had  seen  many  whose  cases 
were  mild  or  shortened,  but  none  which  were  "aborted."  It  is 
a  self-limited  disease.  The  type  here  is  less  severe  than  that 
seen  formerly  in  the  Northern  hospitals. 

Dr.  Knox,  in  reply,  said  that  he  was  not  wedded  to  Wood- 
bridge's  formula,  but  to  the  principle.  He  simply  wished  to 
give  it  a  fair  trial  and  test.  He  believed  in,  and  expected  to 
use,  also  the  eliminative  and  antiseptic  method.  But  not  even 
this  has  accomplished  what  Woodbridge  has  done,  viz.,  caused 
the  temperature  to  touch  normal  within  seven  days.  He  had 
had  three  deaths  in  his  series  of  cases — two  in  which  the  treat- 
ment was  begun  on  the  26th  and  29th  days  respectively,  both 
having  pneumonia;  and  the  third,  in  which  treatment  was  begun 
on  the  2nd  day,  but  both  pneumonia  and  a  severe  jaundice  were 
complications.  Referring  to  the  cases  of  Dr.  Hines  which  died 
of  hemorrhage,  he  would  say  that  the  Woodbridge  method 
lessens  the  stage  of  engorgement  in  Beyer's  patches,  prevents 
the  stage  of  ulceration  and  the  patients,  therefore,  are  not  so 
likely  to  have  hemorrhages.      He  holds  on   to   the  Woodbridge 


SOCIETY  REPOETR, 
l4 

plan  and  will  try  it   in   a  sufficient  number  of  cases   to  satisfy 
himself  further  as  to  its  efficiency. 

HuBKRT  A.   RoYSTER,   M.D.,   Secretary. 


CLINICAL  SOCIETY  OF  ST.  JAMES  DISPENSARY.* 

STATED    MEETING    HELD    DECEMBER    4,     1897. 


DR.   VAN  MARTER  presented    for  examination    a   patient 
who  had  recently   had   mediastinal   abscess,    which   rup- 
tured  into   a  large  bronchus,    discharged   by  coughing, 
and  apparently  cured.     The  case  will  not  now  be  described,  as 
a  paper  is  being  prepared  which   will   describe  it  in    full,    with 
illustrations. 

Dr.  St.  J.  B.  Graham  read  a  paper  on  puerperal  infection,  its 
cause,  pathology   and   treatment   (see  page  5). 

PUERPERAL  INFECTIONS,  ITS  CAUSE  PATHOLOGY   AND   TREATMENT. 
DISCUSSION. 

Dr.  Carson. — As  the  subject  under  discussion  is  the  treatment 
of  puerperal  infection,  I  shall  have  nothing  to  say  of  prophy- 
laxis. Precautions  here  are  universally  recognized,  and  I  would 
simply  state  that  I  of  course  favor  them;  I  cannot,  however, 
accept  such  vigorous  treatment  as  the  use  of  a  stiff  brush  in  the 
vagina. 

I  wish  that  the  essayist  of  the  evening  had  seen  fit  to  bring 
out  in  sharper  lines  the  two  very  distinct  types  of  puerperal  in- 
fection, namely,  the  sapraemia  and  the  septicaemia,  one  a  much 
less  dangerous  condition  and  amenable  to  local  treatment,  the 
other  a  very  serious  condition,  and  one,  unfortunately,  very 
much  less  amenable  to  treatment,  local  or  general.  In  one  the 
curette  and  the  douche  will  change  for  the  better  all  the  symp- 
toms; in  the  other  the  curette  and  the  douche  may  do  harm, 
especially  the  latter,  rather  than  good,  for  the  system  is  in  a 
condition  of  great  depression  and  any  additional  shock  may 
make  matters  worse.  In  one  the  pulse  is  good,  though  the 
^Savannah  Ga. 


SOCIETY  REPORTS.  j  - 

fever  may  be  high;  in  the  other  pulse  is  bad  and  the  fever  not 
so  high  usually.  I  speak  of  the  ill  effects  of  the  douche  in  the 
former,  as  I  had  a  fatal  case  of  puerperal  septicoemia  which  I 
think  would  have  recovered  had  I  not  used  the  douche,  and  the 
douche  used  with  every  precaution.  In  septicaemia,  the  blunt 
curette  and  the  douche,  with  a  good  drain,  will  cure  probably 
99  percent,  of  the  cases  if  used  early;  in  septicaemia  proper, 
with  the  bad  pulse  from  the  beginning,  with  few  or  no  symp- 
toms of  local  trouble,  with  anxious  countenance  and  sweet 
breath,  and  sweats,  the  large  majority  will  die  in  spite  of  all 
treatment,  for  we  have  the  blood  surcharged  with  an  animal 
poison,  which  requires  in  all  probability  an  antitoxine  to  anti- 
dote it.  The  anti-streptococcic  serum  now  under  trial  still  re- 
quires very  careful  investigation  to  prove  its  utility.  I  have  had 
no  experience  with  it. 

Fortunately  for  us  the  majority  of  the  cases  of  puerperal  in- 
fection which  come  to  us  are  saprsemia,  and  are  usually  easily 
controlled,  j  My  own  experience  leads  me  to  view  with  favor 
very  foul  lochia.  The  saprsemia  seems  to  antagonize  the  more 
virulent  toxine.  I  have  yet  to  have  a  death  where  it  existed, 
whilst  all  my  fatal  cases  have  shown  little  or  no  fetor  or  evi- 
dences of  local  trouble. 

As  antiseptics  I  shall  still  cling  to  HgCl,,  carbolic  acid  and 
creoline.  Any  torn  vaginal  or  perineal  surface  I  should  unite 
at  once.  Never  the  cervix,  however,  as  it  would  tend  to  narrow 
or  close  this  natural  outlet  for  the  lochia.  I  am  absolutely  op- 
posed to  touching  torn  vagina  or  cervix  with  iodine  or  strong 
carbolic  acid  as  discouraging  speedy  union,  believing  that  the 
usual  antiseptic  douche  will  clean  all  abraided  surfaces.  If  we 
have  chancroids  or  phagadenic  sores  to  treat  it   is  time  enough 

course,    nothing  less 
than  HNO3. 

I  am  opposed  to  the  coal  tar  group  except  in  small  doses  for 
analgesic  effects.  When  used  as  antipyretics  they  injure  the 
patient  and  deceive  the  physician.  I  have  seen  physicians  pre- 
scribe veratum  veride  in  fulminating  septicaemia,  and  rubbing 
their  hands  Vv^ith  glee  because  the  pulse  had  been  brought  down 
to  70  from_i4o,  and  the  patient  was  dying. 

I  believe  in  free  catharsis   in   the  beginning,    and  keep  up  in 


jg  SOCIETY  REPORTS. 

certain  cases.  In  ordinary  septicaemia  I  give  quinine  with  nitric 
acid.  In  marked  septicaemia  I  drop  all  drugs  but  alcohol  in 
large  quantities  and  morphia  for  sleep. 

I  have  had  in  two  very  severe  cases  wonderful  results  from  ice 
over  the  e/itire  abdomen,  and  kept  there  for  days,  with  the  skin  of 
the  abdomen  as  red  as  a  boiled  lobster.  I  find  it  generally  re- 
commended by  the  authorities. 

I  encourage  the  taking  of  large  quantities  of  fluids;  pepton- 
ized milk,  and  whiskey  and  water,  and  barley  water  in  the  place 
of  plain  water.  Subcutaneous  injections  of  normal  salt  solu- 
tion, or  intravenous  injections  of  the  same. 

While  it  may  be  easy  enough  to  know  /io7c<  to  interfere  it  is 
not  so  easy  to  know  when.  Many  cases  have  the  slight  septic 
fever  on  the  third  day,  known  as  the  "milk  fever,"  lasting  from 
24  to  48  honrs,  which  disappears  spontaneously  and  amounts  to 
nothing.  Here  interference  would  be  officious.  But  if  this 
fever  starting  on  the  third  day,  rises  above  loi,  say,  with  a  cer- 
tain amount  of  uterine  tenderness  and  a  uterus  larger  than  it 
should  be  at  this  stage  of  the  puerperium,  with  scanty  or  sup- 
pressed lochia,  or  lochia  with  more  or  less  fetor,  a  furred  tongue 
and  general  malaise,  we  have  before  us  a  clinical  picture,  not 
very  uncommon,  and  which  yields  to  a  proper  curettage  and 
douche,  with  a  m^ercurial  purge  and  a  saline.  I  am  sure  we 
have  all  done  ourselves  credit  in  these  cases.  To  do  these  cases 
properly  an  anaesthetic  may  or  may  not  be  necessary  ;  it  depends 
upon  the  patient.  I  have  curetted  many  without  anything. 
Others  would  not  permit  the  introduction  of  a  speculum  with- 
out an  anaesthetic. 

But  if  we  have  before  us  a  case  where  the  pulse  is  rapid  and 
weak,  where  the  patient  has  a  dejected  and  anxious  look,  and 
where  usually  the  fever  is  out  of  all  proportion  to  the  gravity 
of  the  other  symptoms,  and  where  the  local  symptoms  are  in- 
significant apparently,  we  have  before  us  a  clinical  picture 
which  is  totally  different  from  the  first  and  which  shows  strong 
Rembrandt  shadows  with  very  little  light.  If  we  interfere 
locally  it  must  be  under  an  anaesthetic,  for  the  system  is  already 
under  a  profound  shock  add  any  further  shock  must  aggravate. 
We  shall  find  usually  that  there  is  no  great  amount  of  uterine 
debris  to  be  brought  away.  The  fact  of  the  matter  is  the  poison 
has  long  before  leaped  the  uterine  barrier  and  is  far  away  from 


SOCIETY  KEPORTS.  jy 

curette  or  douche.  In  the  large  majority  of  the  cases  it  is  even 
beyond  hysterectomy.  This  latter  step  is  not  to  be  considered, 
however,  unless  the  operator  knows  his  business  well.  I  am 
far  from  being  satisfied  with  the  cases  so  far  reported. 

Dr.  Fitch. — Dr.  Graham  has  so  thoroughly  covered  this  sub- 
ject that  there  is  not  much  to  bring  out  in  the  discussion,  since 
my  treatment  so  completely  coincides  with  his.  However,  we 
will  endeavor  to  illustrate  the  differential  diagnosis  of  two  forms 
of  septic  infection  most  commonly  met  with — sapraemia  and 
septicemia. 

Sapraemia  is  a  disease  due  to  an  introduction  into  the  system 
of  the  products  of  putrefaction;  these  products  are  produced 
by  many  different  schizomycetes,  the  so-called  saprophytes — 
minute  organisms  which  are  allied  to  algae  and  are  found  all 
over  the  world  in  streams,  plants  and  animals.  By  their  growth 
and  multiplication  these  organisms  produce  certain  chemical 
substances,  the  so-called  toxins,  a  kind  of  ptomains  which  give 
rise  to  fevers.  Ptomains  are  alkaloids  produced  in  dead  animal 
tissues  during  putrefaction. 

Septicemia  is  a  disease  due  to  a  few  well  known  microbes  that 
actively  enter  the  tissues  and  blood  with  or  without  the  local 
seat  of  infection ;  these  microbes  are  almost  exclusively  strep- 
tococci pyogenes  and  staphilococci  and  the  bacilli  of  Kloebs  and 
Loefifler. 

The  treatment  of  sapraemia  easily  falls  under  four  heads;  the 
only  discussion  is,  as  to  the  best  methods  to  obtain  the  objects 
sought  for,  which  are, 

ist.  To  cleanse  the  parturient  canal.  2d.  To  secure  tonic 
uterine  contractions.  3d.  To  control  temperature.  4th.  To 
support  your  patient. 

The  (yiily  point  worth  of  mention  overlooked  by  Dr.  Graham 
in  his  treatment  was  transfusion.  In  cases  of  septicemia,  where 
the  patient  is  dying  from  toxine  poisoning,  if  you  bleed  on  the 
right  side  and  use  an  intravenous  injection  of  blood  from  a 
healthy  subject,  or  the  normal  saline  solution  injected  into  the 
left  side,  or  vice  versa,  you  will  rid  your  patient  of  apart  of  the 
poison  that  is  destroying  her  chances  of  recovery.  I  have  known 
lives  saved  by  this  means  of  treatment. 

Dr.  Lanier. — In  reviewing  Dr.  Graham's  paper  I  would  men- 
tion that  in  giving  the  cause  of  puerperal  infection  he  failed  to 


jg  SOCIETY  EEPORTS. 

mention  the  fact,  which  has  been  established  beyond  doubt,  that 
there  is  a  form  of  infection  during  the  puerperium   where   the 
source  of    in  fection   or  entrance  is  not   through    the    genital 
organ  of  the  patient,  but  the   micro-organism   does  pass   from 
the  large   intestine   into   the  uterus  and   its   appendages,    and 
causes  uterine   symptoms   identical  with   those   observed  after 
direct  infection  by  the  streptococcus.     This  condition  is  usually 
found  only  in  women  who  are  constipated,  with  a  dilated  colon, 
usually  occurring  several  days  after  confinement.      Keeping  the 
patient's  bowels  freely  open  will  usually  prevent  this  condition. 
Likewise,  we  often  cure  such  a  condition  by   free  catharsis.      I 
mention  this  point,  not  because  I    would   name  the   condition 
along  with  puerperal  septicaemia,  but  because   it   is   highly   im- 
portant for  us  to  know  every  phase  of  puerperal  fever  in  order 
that  we  might  meet   the   enemy — sepsis   or   toxaemia — with  our 
tactics  arranged  for  war  and  destruction  to  the  micro-organisms 
and    toxines.      We   all    agree   with   Dr.  Graham   as   to  common 
sources  of  infection  in  the  lying-in  woman,  but  I  would  like  to 
ask  the  question,  why  is  it  that  although  all  the  country  negroes 
and  poor  whites  are  waited  on  by   ignorant  midwives,  who  not 
ouly  use  lard   and   greases   of  various   kinds   to  lubricate  their 
fingers  to  examine  the  condition  of  the  os  and   presentation  of 
the  child,  without  having  even  washed   their  hands,  and  with  a 
total  lack  of  cleanliness  from  beginning  to  end — why  is  it,  I  say, 
that  only  a  very  few  of  these  women  ever   have  any  trouble  to 
follow  labor?     Is  it  possible  that  micro-organisms  which  develop 
puerperal  sepsis  are  not  always  present  with  the  accoucher  and 
around  the  patient? 

In  the  hands  of  modern  obstetricians  we  rarely  hear  of  any 
sepsis  following  child-birth,  but  there  are  a  sufficient  number  of 
cases  occurring  to  remind  us  of  the  necessity  for  being  careful 
in  the  management  of  our  patients.  It  is  my  opinion  that  if 
we  take  every  precaution  that  is  known  to  the  laparotomist,  our 
patient  cannot  develop  sepsis  any  oftener  than  we  should  look 
for  septic  peritonitis  in  a  patient  upon  whomj  a  clean  laparo- 
tomy had  been  performed  where  there  was  no  pus  encountered. 
I  would  map  out  the  following  course  for  the  prevention  of 
infection  in  the  puerperal  patient,  viz:  When  labor  has  begun 
and  tlje  doctor  has  arrived  it  would^^be  his  duty  to  order,  first. 


SOCIETY  REPORTS.  jq 

a  general  warm  bath  and  good  scrubbing  of  the  woman,  a  free 
cathartic  dose  of  a  saline,  free  saline  vaginal  douche;  second, 
dress  patient  in  clean  clothes,  have  perfectly  sterilized  sheets, 
napkins  and  towels  for  her;  third,  with  tr.  green  soap  and 
water  and  razor  shave  thoroughly  the  pubic  and  vulvar  region, 
and  with  clean  hands  and  sterilized  warm  water  clean  the  vagina, 
and  of  course  wash  the  vulvar  region  thoroughly  and  apply 
sterilized  gauze  or  napkins,  to  remain  except  when  removed  by 
the  accoucher  for  examination;  fourth,  the  physician  must 
always  have  his  hands  surgically  clean  when  he  examines  the 
vagina  or  the  os  uteri;  fifth,  last  of  all  keep  scrupulously  clean 
everything  that  touches  the  genitalia  of  the  patient  from  the 
beginning  of  labor  until  the  patient  is  dismissed. 

I  am  heartily  in  favor  of  using  the  finger  in  the  vagina  to  find 
out  the  progress  of  labor,  instead  of  depending  upon  the 
method  of  external  palpation  and  auscultation,  and  if  the  patient 
and  the  doctor  are  both  clean  there  will  be  no  danger  of  infec- 
tion from  examination. 

It  does  not  come  to  my  mind  that  it  is  possible  for  the  physi- 
cian to  satisfactorily   determine   the   position  of  the  child,    nor 
the  progress  of   the  labor,    except    by   using   the  finger  in    the 
vagina.      I  believe  the  obstetrician    should   feel  as   free  or  freer 
to  make  frequent  vaginal  examinations  during  labor  as  the  sur- 
geon does  in  having   his   hands  in    an   open    wound.      Further- 
more, it  would  prove  very  unsatisfactory  to  the  general  practi- 
tioner to  be  compelled  to   make   out  the   progress  of  labor   by 
the  outside  method,  for  oftentimes  it  is  important  to  make  other 
visits  or  attend  operations,  therefore  the  only  certain  way  to  as- 
certain the  stage  of  the  descent  and  condition  of  the  birth  canal 
is  to  put  the  finger  in    the  vagina.      While   I   advocate   perfect 
asepsis  in  the  lying-in  room,  I  am  aware  that  the   difficulties  to 
be  frequently  met  are  almost   insurmountable;   especially   does 
this  apply  to  the  general  practitioner  who  cannot  exactly  choose 
his  patients  or  their  nurses;  and  right   here  gentlemen,  let   me 
state  that  I  believe  we  are  as  a  rule  too  lax  in  allowing  our  con- 
finement cases  to  be  nursed  by  anybody   whom  the  family  hap- 
pens to  engage.      Since  it  is  upon  us  that  the  responsibilities  lie, 
and  the  abuses  fall,  it  should  be  our  part  to  insist  upon  havino- 
an  experienced  nurse,  who  is  either  known  to  us  or  who  comes 
well  recommended  by  other  physicians. 


SOCIETY  REPORTS . 
20 

For  a  number  of  years  I  have  made  it  a  rule  to  curette  the 
uterus  and  irrigate  it  with  a  bi-chloride  solution,  afterwards 
washing  this  out  with  plain  water,  and  lastly  applying  tr.  iodine 
to  the  endo-metrium,  and  leaving  in  the  uterus  one  30-grain 
iodoform  suppository.  This  has  been  my  course  in  nearly  every 
case  of  fever  during  the  puerperium  where  I  could  not  throw 
out  simple  fever  of  a  non-septic  character.  When  this  method 
is  carefully  followed  cue  daily  treatment  is  usually  sufficient  to 
combat  any  sepsis  arising  from  the  genital  tract.  Indeed,  I 
have  several  times  seen  cases,  which  I  knew  positively  to  be  of 
a  severe  type,  promptly  yield  to  one  or  two  such  treatments. 
In  fact,  it  has  been  my  good  luck  for  the  past  eight  years  not  to 
lose  a  case  from  puerperal  fever,  whereas,  previously  it  was  my 
ill  luck  to  lose  three  women  from  puerperal  septicaemia  within 
a  period  of  about  two  years. 

I  assure  you  gentlemen  who  are  not  familiar  with  puerperal 
fevers  that  there  is  no  picture  to  come  before  the  eyes  of  a  med- 
ical man  which  so  completely  paralyzes  his  means  to  cope  with 
disease  than  does  the  one  where  a  woman  is  thoroughly  satu- 
rated with  puerperal  sepsis,  who  is  dying  before  your  eyes  with 
blood  poisoning,  and  you  are  forced  to  see  her  die,  knowing 
that  you  are  powerless  to  save. 

It  is  to  be  hoped  that  serum -therapy  will  yet  give  to  us  a 
remedy  which  will  enable  us  to  save  the  lives  of  all  women  who 
develop  puerperal  septicaemia. 

Dr.  Lattimore. — In  Dr.  Graham's  paper  in  the  discussion 
which  is  now  on,  the  ground  of  puerperal  infection  has  been 
pretty  well  covered,  and  as  the  hour  is  late  I  will  limit  what  I 
have  to  say  to  a  question  or  so  and  a  few  remarks.  I  v/ould 
Itke  to  ask  Dr.  Graham  whether  he  is  an  advocate  of  a  hot 
bichloride  vaginal  douche,  1-5000,  immediately  after  the  com- 
pletion of  third  stage  of  labor;  if  not,  why  not?  I  favor  such 
a  douche,  as  it  removes  clots  from  the  vagina  and  thoroughly 
cleanses  it,  and  in  addition,  reflexly,  brings  out  a  good,  vigor- 
ous contraction  of  the  uterus. 

I  should  also  like  to  ask  Dr.  Carson  whether  he  favors  curette- 
ment  in  cases  where  he  is  sure  that  the  placenta  and  membranes 
have  come  away  intact;  if  so,  why? 

Dr.  Graham  has  fully  outlined  the  preventive  treatment  of 
septicaemia,  and  on  all  of  which  I  thoroughly  agree   with  him. 


SOCIETY  REPORTS.  2  t 

Now,  as  to  the  treatment  of  the  actual  condition  of  septicaemia, 
with  special  reference  to  the  advisability  of  the  uterine  douche 
in  cases  where  the  uterus  is  known  to  be  free  from  placenta, 
membranes  and  clots.  As  to  the  wisdom  of  the  douche,  my 
mind  is  not  quite  made  up.  It  seems  to  me  that  sometimes  the 
thrombi  closing  the  mouths  of  the  uterine  sinuses  are  washed 
away  by  the  douche,  rapid  absorption  takes  places,  and  very 
soon  is  followed  by  a  chill  and  collapse. 

Now  we  come  to  the  second  form  of  puerperal  infection,  viz: 
sapraemia.  To  my  mind  the  best  plan  to  avoid  this  form  of  in- 
fection is  as  follows: 

1.  Be  sure  of  asepsis. 

2.  Be  careful  to  observe  whether  placenta  and  membranes 
have  come  away  complete.  If  membranes  not  complete,  then 
either  go  into  the  uterus  just  after  the  third  stage,  or  24  hours 
later,  with  Tucker's  membrane  forceps,  anjesthetic  unnecessary. 
Then  we  at  least  feel  sure  that  the  uterus  is  free  from  debris. 

3.  In  a  third  class  of  cases  we  found  that  a  set  degree  of 
sapraemia  was  due  to  the  following  cause,  viz:  Poor  drainage, 
the  uterus  was  deflected  to  either  side  or  had  become  markedly 
antiflexed  or  retroverted,  forming  an  acute  angle  of  the  cervix, 
thus  damming  back  the  lochia,  resulting  in  a  foetid  odor  and 
some  fever.  This  cause  was  always  thought  of  in  cases  where 
we  were  sure  of  our  asepsis  and  that  everything  had  come  away 
complete.  I  say  sure  of  asepsis,  as  some  cases  were  brought  in 
on  the  ambulance,  in  labor,  when  we  had  no  time  for  prepara- 
tory cleansing.  In  the  above  cases  by  correcting  position  of 
uterus  and  giving  hot  douches,  the  fever,  which  ran  from 
100-102. 5,  quickly  subsided. 

Mr.  Chairman  and  gentlemen,  the  result  of  my  experience 
and  observation  has  been,  that  not  very  uncommonly  during 
puerperal  convalescence  the  fever  is  due  to  other  trouble  than 
in  the  parturient  canal,  and  we  should  think  of  the  following 
causes  of  fever  and  at  least  exclude  them  from  the  etiology: 

(a)  Common  causes  of  fever,  malaria,  tuberculosis,  tonsilitis, 
etc. 

(b)  Breasts — abscess  forming. 

(c)  Bowels— constipation  will  easily  cause  temperature  of  100- 
102°,  which  goes  down  when  bowels  are  moved. 


SMALL-POX  IN  GEORGIA. 
22 

(d)  Be  sure  to  have  vulva  good,  clean  and  sterile,  and  if  hot 
douches  are  ordered,  look  after  douche  bag,  points,  etc.,  so 
that  there  is  no  chance  of  infection  from  that  source. 

I  agree  with  Dr.  Lanier,  that  frequent  examination  during 
labor  is  wise,  as  the  progress  of  labor  can  thus  be  accurately 
ascertained.  Of  course  it  is  understood  that  fingers  are  clean 
before  introduction  into  vagina. 


SMALL-POX  IN  GEORGIA. 


It  is  reported  that  small-pox  prevails  in  thirty  counties  in 
Georgia.  The  epidemic  in  Atlanta  will  cost  the  commercial  in- 
terests of  the  city  over  $1,000,000  during  the  holiday  season 
alone.  Compulsory  vaccination  here  has  had  the  effect  of 
frightening  the  country  people  away  from  Atlanta.  In  Atlanta 
there  has  been  120  cases  of  small-pox,  but  no  deaths.  Accord- 
ing to  a  report  in  the  daily  papers.  Col.  E.  E.  Cavaleri,  a  vet- 
eran of  the  Union  army,  seventy-four  years  of  age^  has  sued 
the  city  of  Atlanta  for  damages.  When  the  city  physicians 
were  recently  making  their  vaccination  rounds,  Colonel  Cava- 
X\tx\'s>  fiaricee^  objected  to  vaccination,  saying  she  was  about  to 
be  married.  The  doctor  told  her  it  was  better  to  be  vaccinated 
than  married,  ard  persuaded  her  to  be  vaccinated.  When 
Cavaleri  came  next  to  see  her,  she  told  him  she  had  decided  to 
follow  the  doctor's  advice,  and  refused  to  marry  him ;  hence  the 
suit  for  damages. — Boston  Med.  and  Surg.  Jour. 


NORTH  CAROLINA  MEDICAL  JOURNAL, 


ROBERT  D.  JEWETT,  M.D.,  Editor. 


COLLABORATORS 

GEORGE    GILLETT    THOMAS,    M.  D. ,  S.    WESTRAY    BATTLE,    M.D.,    U.S.N 

HENRV    T.    BAHNSON,    M.D.,  ROBERT    S.    YOUNG,    M.D., 

J.    ALLISON    HODGES,    M.D,  HUNTER    MCGUIRE,    M.D.,    LL.D. 

This  Journal  is  published  on  the  fifth  and  twentieth  of  each  month,  and 
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fact  to  this  office.  .  u-    t 

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nal only)  requiring  illustrations,  free  of  cost  to  the  author. 

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ton, N.  C. 


lEMtoriaL 


THE  NEW  YEAR. 

To  all  our  friends,  subscribers,  advertisers  and  exchanges,  we 
extend  greeting,  with  our  best  wishes  for  a  happy  and  prosper- 
ous New  Year. 

At  each  annual  mile  post  in  one's  life  journey  it  is  well  to 
stop  and  consider — to  look  back  over  the  path  just  trodden  and 
note  the  hindrances  to  our  easy  progress,  whether  we  have  met 
and  overcome  them  as  we  should;  to  glance  ahead  as  far  as 
possible  upon  the  untrodden  way,  resolved  to  profit  by  our  past 
experiences.  To  no  class  of  men  does  this  apply  more  aptly 
than  to  those  of  the  medical  profession.  None  others  have  to 
face  so  many  difficulties  and  disappointments;  none  others  are 
called  upon  to  grapple  with  so  many  sudden  conditions  requir- 
ing judgment,  coolness  and  courage.  Let  us  look  back  at  those 
cases  which  have  not  done  well  and  ask  ourselves  if  we  have 
done  our  whole  duty.  Let  us  go  farward  into  the  new  year 
determined  to  perform  to  the  best  of  our  ability  the  mission 
that  is  ours — to  give  ourselves  to   our  work  in  a  whole-hearted 


EDITORIAL. 

way— not  to  be  discouraged  by  unfortunate  results,   or  by  lack 
of  appreciation  on  the  part  of  those  for  whom  we   have  toiled. 

With  this  issue  the  Journal  enters  upon  its  twenty-first  year, 
and  in  keeping  with  the  spirit  of  progress  that  has  characterized 
it,  there  will  be  instituted  new  improvements  that  will  com- 
mend themselves  to  our  readers  and  greatly  increase  the  use- 
fulness and  popularity  of  the  Journal.  In  the  first  place,  we 
will  have  a  department  devoted  to  translations  from  foreign 
journals  under  the  able  charge  of  Dr.  Richard  H.  Whitehead, 
of  Chapel  Hill.  Important  papers  appearing  in  French,  Ger- 
man and  Italian  journals  will  be  translated  in  full,  or  full  ab- 
stracts made.  In  this  way  our  readers  will  get  early  and  from 
first  hands  the  results  of  the  labors  of  those  earnest  workers  in 
the  fields  of  medicine.  The  department  of  abstracts  will  be 
divided  into  sections  covering  the  various  branches  of  medicine, 
which  sections  will  be  under  the  charge  of  prominent  North 
Carolina  physicians.  These  gentlemen  will  make  abstracts  of 
original  papers  pertaining  to  their  respective  sections  which  ap- 
pear in  journals  published  in  English,  and  will  follow  the  ab- 
stracts with  comments  over  their  own  initials,  when  they  con- 
sider comment  called  for.  This  portion  of  the  Journal  will  be 
printed  hereafter  in  smaller  type,  thus  improving  its  appearance 
and  affording  an  increased  amount  of  reading  matter. 

We  believe  our  readers  will  appreciate  this  move  as  an  evi- 
dence of  our  desire  to  give  them  the  best  and  most  useful  jour- 
nal in  the  South.  But  we  beg  to  announce  another  move  still 
in  the  interest  of  those  who  really  desire  to  aid  us  in  making 
the  Journal  of  the  State  Society  what  it  should  be.  While  the 
subscription  price  of  the  Journal  will  remain  the  same,  a  dis- 
count of  50  per  cent,  will  be  made  to  those  who  remit  strictly 
in  advance.  This  proposition  is  made  to  induce  advance  pay- 
ment and  to  place  the  Journal  within  easy  reach  of  any  phy- 
sician who  wishes  an  ethical,  practical  and  up-to-date  journal. 

A  few  copies  of  this  issue  will  be  sent  to  members  of  the  pro- 
fession who  are  not  subscribers.  To  these  we  would  say,  it  is  our 
wish  to  have  the  Journal  read  by  every  physician  in  this  sec- 
tion, and  as  it  is  impossible  to  form  a  true  estimate  of  its  value 
from  a  single  copy,  we  will  be  pleased  to  send  the  Journal  on 
trial  for  six  months  on  receipt  of  50  cents  in  stamps. 


tTberapeuttc  Ibints. 


For  Acute  Alcoholism. — The  following  combinations  are 
recommended: 

Ip — Spt.   ammon.    aromat 3  ii. 

Tinct.  camphorae 3  iss. 

Tinct.  hyoscyami 3  iiss. 

Spts.  lavandulae  co q.  s.  ad    §  ii. 

M.    Sig.      One  teaspoooful  every  hour. 
When  acute  symptoms  have  been  relieved  the  following  may 
be  substituted: 

'^ — Pulv.  capsici gr.  xxiv. 

Quininse  sulph gr.  xxxvi. 

M,   Ft.  cap.   No.  xii.  Sig.     One  capsule  before  each  meal 
and  continue  for  several  days. 

Should  insomnia  be  an  element,  administer  the  following: 

IJ — Sodii   bromidi |  ss. 

Chloral,  hydrat 3  iiss. 

Syr.  aurantii  cort f  ss. 

Aquae ad.    |  iv. 

M.  Sig.     A  teaspoonful  at  bedtime  and  repeated  during 
the  night  if  necessary. — Med.  Nerus. — M.  &.  S.  Jour. 

To  Avoid  Otitis  in  Scarlatina. — According  to  Comby, 
the  pharyngeal  cavity  should  be  painted  several  times  a  day 
with  a  lo  percent,  solution  of  rosorcin,  by  means  of  a  cotton 
swab  (this  may  occasionally  cause  oliguria  with  green  or  dark 
urine).  Naphthol-camphor  is  also  recommended  for  this  pur- 
pose, as  follows: 

'^ — B.  naphthol lo.o. 

Camphor 20.0. 

Glycerin 30.0. 

M.      Sig. — For  external  application! — Pediatrics. 

Delivery  by  Forceps. — Dr.  Davis,  in  a  recent  lecture  on 
delivery  by  forceps,  stated  that  the  instrument  which,  at  the  pres- 
ent time,  is  giving  the  most  general  satisfaction,  not  only  in  his 
hands  and  the  obstetric  clinics  in  this  country,  but  also  abroad. 


mSCELLANEOUS  ITEMS. 
20 

is  that  known  as  the  Simpson  forceps.  It  is  necessary  that  the 
instrument  should  be  well  made  and  long  enough  for  high  ap- 
plication. The  efficiency  of  the  forceps  is  greatly  increased  by 
the  use  of  axis  traction  tapes.  These  may  be  passed  through 
the  fenestra,  or,  what  is  better,  the  blades  may  be  perforated  by 
two  holes,  through  which  the  tapes  should  be  passed.  An  axis 
traction  bar,  while  convenient  is  not  essential.— P/'//.  Polyclinic. 


niMsceUaneoue  Utenis. 


"Mister,"  said  the  small  boy  to  the  chemist,  "give  me  another 
bottle  o'  them  pills  you  sold  father  day  before  yesterday." 

"Are  they  doing  him  good?"  asked  the  chemist,  looking 
pleased. 

"I  d'no  whether  they're  doing  father  any  good  or  not,  but 
they're  doin' me  good.     They  just  fit   my   new  air-gun."— ^a-. 

An  Irish  brakeman  in  the  railroad  yards  was  hurt  by  the  train 
and  his  friends  offered  to  send  for  a  physician.  They  asked: 
"Do  you  want  an  allopath  or  homeopath?"  He  replied:  "It 
don't  matter— all  paths  lead  to  the  grave." — Ex. 

The  Georgia  Football  Bill. — Governor  Atkinson,  of  Geor- 
gia, has  vetoed  the  anti-football  bill  which  was  passed  almost 
unanimously  by  both  branches  of  the  legislature.  His  objec- 
tions to  the  bill  are  that  "legislation  which  seeks  to  usurp  the 
responsibility  and  functions  of  trustee,  faculty,  and  parent,  and 
take  charge  of  young  men  and  children  in  their  sports,  is  fun- 
damentally wrong,  it  is  governmental  paternalism  of  the  most 
vicious  and  pronunced  type"  The  governor  says,  however,  "that 
some  legislation  may  be  necessary  to  modify  the  fierceness  of 
football  games,"  seemingly  overlooking  the  fact  that  there  is 
just  as  much  paternalism  in  deciding  upon  the  exact  amount  of 
violence  permissible  in  a  game  as  there  is  in  prohibiting  it.  The 
bill  forbade  the  "sport"  only  when  money  was  charged  for  ad- 
mission to  the  grounds  where  the  game  was  played,  so  that  it 
would  have  been    still    permissible  to  encourage    "aggressive 


MISCELLANEOUS   ITEMS. 


27 


manliness,"  which  the  govenor  defined  as  "a  quality  amalgama- 
ted of  courage,  endurance,  restraint,  and  the  power  to  act  sure- 
ly and  unfalteringly  in  an  emergency — a  quality  which  football 
tends  to  foster  and  to  keep  alive."  But  apparently  an  essential 
to  the  encouragement  of  aggressive  manliness  is  a  good  pot  of 
gate  money. — Med,  Record. 

Dr.  J.  O.  Matthews  has  removed  to  Ora,  N.  C. 

Dr.  E.  F.  Strickland  has  returned  to  his  home  in  Bethania.N.C. 

Our  department  of  ''Abstracts"  has  been  crowded  out  of  this 
issue.  With  our  next  issue,  however,  there  will  appear  much 
interesting  matter  in  this  department. 

The  address  of  Dr.  M.  P.  Perry,  Treasurer  of  the  State 
Society,  is  Macon  and  not  Morganton,  as  it  appears  in  the  list 
of  officers  in  the  Transactions  of   the   Society,  lately  published. 

Mr.  Campbell,  caterer  for  one  of  the  "Messes"  at  the  Uni- 
versity of  Virginia  has  recently  been  robbed  of  $200,  and  a 
medical  student  of  New  Jersey  has  been  arrested  as  being  the 
thief. 

A  New  Adulterartion. — The  Department  of  Agriculture 
has  discovered  that  many  creameries  are  using  an  emulsion  of 
cottonseed  oil,  which,  added  to  the  cream,  increases  the  butter 
product  per  gallon  of  milk,  with  small  chance  of  detection  and 
a  large  increase  from  profit. — Medkal  Record. 

Progress  at  Craig  Colony  During  the  Past  Year. — The 
Craig  Colony  for|epileptics  at  Sonyea,  Livingston  County,  N.Y., 
closed  its  fourth  fiscal  year  September  30,  1897.  There  were 
at  that  ilaie  214  patients  in  the  colony,  the  majority  of  whom 
had  been  transferred  from  the  various  county  houses  through- 
out the  State.  New  buildings  aie  in  course  of  construction 
which,  when  completed,  will  enable  the  colony  to  accommodate 
140  additional  patients,  making  the  total  number  about  350. 
It  is  estimated  by  State  chairty  officials  that  this  number  repre- 


2g  READING  NOTICES. 

sents  about  one-third  of  the  total  number  of  epileptics  now  a 
public  charge  throughout  the  State.  The  medical  superinten- 
dent, Dr.  William  P.  Spratling,  reports  a  great  increase  in  the 
value  of  agricultural  and  industrial  products  of  the  colony  over 
last  year,  so  that  the  ratio  of  earnings  of  the  patients  to  the 
cost  of  their  maintenance  is  even  larger  than  that  of  the  last 
year,  which  was  a  little  over  50  per  cent.  A  laboratory  for  the 
use  of  a  pathologist  and  pathologic  chemist  is  being  constructed. 
Dr.  Christian  A,  Herter  of  New  York  has  '  been  appointed 
pathologic  chemist,  and  Dr.  Ira  Van  Giesen  of  New  York,  con- 
sulting pathologist  to  the  colony.  Dr.  Frederick  Peterson  of 
New  York  was  re-elected  president  of  the  board  of  managers. 
The  managers,  at  their  annual  meeting,  decided  to  ask  the  com- 
ing legislature  for  $200,000  for  dormitory  buildings  in  order 
that  they  may  increase  the  residence  capacity  of  the  colony  for 
patients.  — Medical  Nexus. 


1?eabma  IRoticee, 


F.  E.  Harrison,  M.  D.,  Abbeville,  S.  C,  says:  I  have  used 
Celerina  in  appropiate  cases,  and  can  hearcily  recommend  it  to 
all  who  wish  an  elegant  preparation,  combined  with  undimin- 
ished therapeutic  activity.  It  is  peculiarly  fitted  to  such  cases 
as  delirium  tremens,  headache  from  debauch  or  excessive  men- 
tal or  physical  exertion. 


DOCTOR: — Your  library  is  not  complete  without  the  Hyp- 
notic Magazine.  Cost  of  this  handsome  monthly,  including 
premium  book  on  Suggestive  Therapeutics  is  only  one  dollar 
($1.00)  a  year. 

THE  PSYCHIC  PUBLISHING  CO., 

56  5th  Avenue,   Chicago. 


SYR.  HYPOPHOS.  CO.,  FELLOWS 

Contains  the  Essential  Elementg  of  the  Animal  organization— Potash  and  Lime; 

The  OxidisingAgents — iron  and  Maganese: 

Tlie  Tonics — Quinine  and  Strychnine; 

And  the  Vitalizing  Constituent — Phosphorus;  the  whole  combined  in  the  form  of  a  Syrup  with  a 

Slightly  Alkaline  Reaction. 
It  Differs  in  Its  Effects  from  all  Analogoas  Preparations;  and  it  possesses  the  important  properties 

of  being  pleasant  to  the  taste,  easily  borne  by  the  stomach,  and  harmless  under  pro- 
longed Hse. 
K  has   Gained  a  Wide   Reputation,  particularly  in  the  treatment  of  Pulmonary  Tuberculosis, 

Chronic  Bronchitis,   and  other  affections  of  the  respiratory  orgons.     It  has  also 

been  employed  with  much  success  in  various  nervous  and  debilitating  diseases. 
Its  Coratiye  Power   is  largely  attributable '  )  its  stimulant,  tonic,  and  nutritive  properties, 

by  means  of  which  the  energy  of  the  system  is  recruited. 
Hs  Aetion  is  Prompt;  it  stimulates  the  appetite  and  the  digestion,  it  promotes  assimilation, 

and  it  enters  directly  into  the  circulation  with  the  food  products. 

The  prescribed  dose  produces  a  feeling  of  buoyancy,  and  removes  depression  and  mel- 
ancholy; hencethepreparationisofgreatva^  and  nervou* 
affections.  From  the  fact,  also,  that  it  exerts  a  double  tonic  influence,  and  induces  a 
healthy  flow  of  the  secretions,  its  use  is  indicated  in  a  wide  range  of  diseases. 


NOTICE-CAUTION. 

The  success  of  Fellows'  Syrup  of  Hypophosphites  has  tempted  certain 
persons  to  offer  imitations  of  it  for  sale.  Mr.  Fellows,  who  has  examined 
samples  of  several  of  these,  finds  that  no  two  of  them  are  identical, 
and  that  all  of  them  differ  from  the  original  in  composition,  in  freedom 
from  acid  reaction,  in  susceptibility  to  the  effects  of  oxygen  when  ex- 
posedjto  light  or  heat,  in  the  property  of  retaining  the  strych- 
idne  in  solution,  and  in  the  medicinal  effect«. 

.A.8  these  cheap  and  inefficient  substitutes  are  frequently  dispensed  ii- 
stead  of  the  genuine  preparation,  physicians  are  earnestly  requested, 
when  prescribing  the  Syrup,  to  write  "Syr.  Hypophos.  Fellows." 

As  a  further  precaution,  it  is  advisable  that  the  Syrup  should  be 
Drdered  in  the  original  bottles ;  the  distinguishing  marks  which  the  bot- 
tles (and  the  wrappers  surrounding  them)  bear,  can  then  be  examined, 
and  the  genuineness — or  otherwise— of  the  contents  thereby  proved. 


lUDICAL  LBTTERS  MAY  B3  ADDRESSED  TO 


48  Vesey  Street,  New  York. 


^oiitli.    Write  to  J.  T.  PATKICK    for  iBirormation. 


T«,.n.y-Fn-,t   V«r.  JANUARY    20,    l8^.  Vol.  41.     NO.  2. 

NORTH  CAROLINA 

MEDICAL  JOURNAL. 

PUBLISHED  SEMI-MONTHLY  AT  ?2.oo  PER  ANNUM. 

IRobert  ID.  Jewett,  m,D..  i£bitoi\ 

[Entered  at  the  Post-Office  at  Wilmington,  N.  C,  as  Second-class  mail  matter. j 


fmtmfmtmm4w\ 


ORTHOPEDIC   ^m     Trusses 
Instruments.     "      "«•*"■ 


E.  A.  YARNALL  &  CO., 

Philadelphia  Surgical  Instrument  House, 

1020  WALWIJT  STREET,  PHILADELPHIA. 
Catalogue  sent  on  Application. 


I 


NORTH  CAROLINA 

MEDICAL  JOURNAL 


A  SEMI-MONTHLY  JOURNAL  OF  MEDICINE  AND 
SURGERY. 


Vol.  XLI.  Wilmington,  January  20,    1898.  No.   2. 


Original  Communicationa. 


PUERPERAL    ECLAMPSIA  AND  ITS  TREATMENT. 
By  D.   a.    Stanton,   M.D.,   High  Point,  N.  C. 


CONSIDERING  puerperal  eclampsia  to  be  the  most  danger- 
ous complication  of  pregnancy  that  the  physician  is 
called  upon  to  treat  and  that  there  is  no  disease,  concern- 
ing the  pathology  of  which  so  little  is  positively  known  and  in 
which  better  results  are  obtained  by  proper  treatment,  is  my 
excuse  for  submitting  this  paper.  While  it  is  stated  that  this 
complication  of  pregnancy  occurs  only  once  in  about  300  cases 
of  confinement,  that  is  sufficiently  often  to  keep  the  obstetri- 
cian on  the  look-out  for  it,  and  always  prepared  to  meet  it  when 
it  does  occur.  The  comparatively  rare  occurrence  may  be  ex- 
plained by  the  fact  that  the  convulsive  seizures  are  not  depen- 
dent upon  a  single  cause,  but  that  in  all  probability  a  combina- 
tion of  causes  is  required  for  their  production.  Many  theories 
have  been  advanced  to  explain  the  nature  of  eclampsia,  but 
none  have  proved  satisfactory  and  the  etiology  of  this  grave 
complication  of  labor  is  still  an  undecided  question.  The 
theory  which  has  had,  possibly,  the  most  advocates  and  which 
still  stands  preemenent  in  the  discussion  on  the  etiology  of 
eclampsia  is  based  upon  the  investigations  of  Lever,  who  first 
called  attention  to  the  relation  between  albuminuria  and  puer- 
peral convulsions.     This  theory  however  for  a  time  lapsed  and 


^  Q  STANTON.-PUEEPERAL  ECLAMPSIA  AND  ITS  TREATMENT, 

Others  took  its  place;  but  recently  it  has  received  renewed  at- 
tention, and  at  the  present  is  being  considered  equal  to  if  not 
of  more  importance  than  some  of  more  recent  origin. 

That  Bright's  disease  was  always  present  in  true  eclampsia 
could  not  be  sustained,  many  cases  occurring  where  no  albu- 
minuria or  kidney  lesion  could  be  found.  Urinary  strain  due 
to  pressure  of  the  gravid  uterus  upon  the  ureters  causing  renal 
lesions  and  subsequently  convulsions,  was  a  theory  proven  un- 
tennable  by  post-mortem  examinations.  Pressure  upon  the 
ureters  by  the  fetal  head,  pressure  upon  the  blood  vessels  caused 
by  premature  descent  of  the  fetal  head  in  the  pelvis,  are  two 
theories  which  failed  to  accomplish  accepted  explanation. 

The  hypothesis  that  the  convulsions  are  the  result  of  an  acute 
cerebral  anasmia  was  advocated  and  found  to  be  inadequate  of 
itself.  Increased  arterial  pressure  resulting  from  hypertrophy 
of  the  left  ventricle  of  the  heart  caused  in  hydremic  patients 
oedema  of  the  brain,  which  by  compression  of  the  cerebral  vessels 
resulted  in  acute  anaemia  with  its  consequent  convulsions  and 
coma. 

The  influence  exerted  by  gestation  upon  the  nervous  system 
the  increased  nervous  excitability,  often  so  marked  in  primipar- 
ous  women,  led  the  old  obstetricians  to  regard  eclampsia  as  a 
reflex  neurosis. 

Sudden  emotion,  anxiety  and  fright  were  looked  upon  as  the 
cause  which  provoked  the  paroxysms.  The  notion  that  puer- 
peral eclampsia  is  dependent  upon  a  toxemia  has  recently  had 
many  advocates  and  is  worthy  of  consideration,  along  with  the 
other  causes,  since  it  is  conceded  that  the  paroxysms  are  not  de- 
pendent upon  any  one  cause. 

The  above  are  only  a  few  of  the  many  causes  credited  with 
producing  eclampsia  in  the  pregnant  woman.  While  no  one  is 
ienahle  J>er  se,  all  have  a  place  of  more  or  less  importance  in 
working  out  the  pathology  of  the  trouble.  It  is  plain  to  see 
that  with  all  the  credited  causes  enumerated,  and  many  more 
that  could  be,  that  the  pregnant  woman  is  in  a  favorable  con- 
dition for  her  blood  to  become  surcharged  with  not  only  urea, 
but  other  effete  materials  productive  of  retrograde  metamor- 
phosis of  the  maternal  tissues  and  constructive  and  retrograde 
tissue  fetal  changes. 

With  all  these  morbific  materials  in  the  individual,   whose 


ST  ANTON. -PUEEPERAL  ECLAMPSIA  AND  ITS  TKEATMENT.  ,  j 

nervous  system  is  susceptible,  "for  not  every  woman  virho  would 
show  some  indication  of  lack  of  proper  excretion  would  de- 
velop eclampsia,"  we  may  have  puerperal  eclampsia  as  a  re- 
sult. 

Without  going  further  into  the  etiology  of  puerperal  con- 
vulsions we  will  come  to  the  treatment,  as  there  could  hard- 
ly be  a  mistake  in  the  diagnosis  of  this  trouble.  The  treat- 
ment is  prophylactic  and  curative;  but,  as  we  see  only  a  small 
proportion  of  the  cases  we  actend  prior  to  the  beginning  of 
labor,  we  have  an  opportunity  to  do  but  little  in  the  way  of 
preventive  treatment.  The  responsibility  of  managing  a  case 
of  puerperal  convulsions,  as  a  rule,  breaks  suddenly  upon  us, 
hence  the  necessity  of  having  even  defined  rules  of  practice 
laid  down  and  thoroughly  established  in  our  minds. 

It  matters  little  what  the  cause  or  causes  are  which  precipi- 
tate the  attack,  so  far  as  treatment  is  concerned.  We  know  a 
Donvulsions  when  we  see  it,  and  also  know  that  unless  we  do 
something  to  stop  them  the  lives  of  two  beings  are  in  jeepardy, 
and  that  each  succeeding  convulsion  greatly  increases  the  danger 
to  mother  and  child. 

Like  the  causes  of  puerperal  eclampsia,  the  remedies  are 
many;  but  unlike  a  positive  factor  in  the  production  of  the 
eclamptive  seizure,  we  have  one  agent,  at  least,  that  can  be  re- 
lied upon  to  control  a  very  large  majority  of  the  cases.  This 
agent  is  tr.  veratrum  viride.  Those  who  have  used  the  remedy 
I  am  sure  will  agree  with  me  when  I  say  that  it  occupies  en- 
tirely too  obscure  a  position  in  our  professional  advancements. 

Why  this  sovereign  remedy  has  not  attained  a  wider  reputa- 
tion is,  I  think,  due  to  feared  depression  following  its  use,  a 
fear  entirely  unfounded. 

This  statement  is  borne  out  by  the  absence  of  a  single  recorded 
case  of  death,  so  far  as  I  have  been  able  to  find,  attributable  to 
its  use  in  eclampsia. 

In  ten  cases  which  I  have  seen  in  my  own  practice  and  in  con- 
sultation, all  yielded  promptly  to  the  influence  of  tr.  veratrum 
viride,  except  one.  This  was  in  the  case  of  a  physician's  wife 
and  on  account  of  his  fear  of  the  drug.  I  was  not  allowed  to 
give  a  full  dose.  Only  five  drops  were  given  and  even  this 
small  amount  reduced  the  pulse  from  120  to  70  and  held  the 
convulsions  in  abeyance  for  three  hours. 


SmTHWICK.-HElMORRHAGIC  FEVER. 

The  promptness  with  which  the  convulsions  are  arrested,  just 
as  soon  as  the  action  of  the  veratrum  viride  on  the  heart  is  evi- 
dent, is  marked. 

The  drug  acts  directly  on  the  cardiac  muscle  and  also  produces 
vasomotor  paresis.  The  immediate  arrest  of  the  convulsions  is 
important  for  there  is  peril  in  the  convulsions  themselves.  The 
remedy  mentioned  will  not  only  arrest  the  attack  most  satisfac- 
torily, but  will  also  stimulate  the  activity  of  the  kidneys  and  skin. 

Blood-letting,  the  time  honored  remedy,  within  the  range  of 
safety  will  not  produce  these  results  so  well,  and  the  patient  is 
none  the  worse  after  the  administration  of  the  veratrum  viride, 
which  cannot  be  said  of  blood-letting. 

The  treatment  is  not  at  all  dangerous.  An  adult,  if  kept  in 
the  recumbent  position,  may  take  20  to  30  drops  hypodermati- 
cally  without  danger.  If  it  should  cause  depression  alcoholic 
stimulants,  strychnine,  or  digitalis  will  produce  prompt  reac- 
tion. It  is  also  fortunate  that  morphine,  which  is  very  useful 
in  counteracting  any  depression  produced  by  the  drug,  is  itself 
a  potent  agent  in  controlling  the  convulsions. 


HEMORRHAGIC  FEVER.— A  REPORT  OF  TWO  CASES. 
By  J.  W.  P.  Smithwick,  M.D.,  Aurora,  N.  C. 


DURING  the  summer  just  past,    I  have  attended   two  cases 
of  hemorrhagic  fever  (malarial  haemoglobinuria),  which  I 
have  studied  as  best  I  could  by  the  aid  of  the  microscope 
and  other  appliances  I  had  at  hand  ;  at  the  same  time,  observing 
the  effects  of  the  different  remedies  administered. 

Case  I. — A  girl  12  years  of  age.  When  I  was  called  I  elicited 
the  following  history,  to  wit:  She  had  been  having  chills  every 
other  day  for  a  week  and  a  half  or  two  weeks,  for  which  qui- 
nine had  been  irregularly  administered,  but  the  chills  would 
return  in  a  day  or  two  after  its  effects  passed  off.  She  had  had 
a  chill  early  that  morning,  and  about  two  hours  later  had  a 
copious  hemorrhage  from  the  bladder  which  was  the  direct  cause 
of  my  being  called.  I  found  her  sitting  up,  temperature  io2°F., 
pulse  much  accelerated  and  quite  feeble,   skin  and  conjunctivae 


SMITHWICK— HEMORRHAGIC  FEVER.  ,. 

thick  and  yellow  in  appearance,  bowels  inactive,  tongue  coated 
with  a  thick  and  yellowish-brown  coating,  on  the  central  and 
back  portions,  white  on  the  edges,  some  tenderness  in  the  splenic 
and  hepatic  regions,  spleen  perceptibly  enlarged,  and  stomach 
somewhat  nauseated.  I  examined  the  discharge  of  urine  and 
found  that  it  was  the  peculiar  wine  color  so  characteristic  of  the 
disease. 

I  directed  the  patient  to  be  put  to  bed,  and  kept  in  a  recum- 
bent position.  I  then  ordered  the  following  medicines:  Satu- 
rated solution  of  sodium  hyposulphite  in  doses  of  a  half  tea- 
spoonful  every  two  hours  for  the  first  rwelve  hours,  and  there- 
after at  intervals  of  four  hours;  and  hj'drag.  chlor.  mit,  grs. 
ij.  and  sod.  bicarb,  grs.  viij,  to  be  made  into  nine  powders,  and 
one  given  every  hour,  also  directed  mustard  plasters  to  be  ap- 
plied over  regions  of  the  liver  and  spleen.  She  got  along  very 
well  that  day,  but  the  next  day  late  in  the  afternoon  she  had 
another  paroxysm  with  slight  hemorrhages.  I  then  ordered,  in 
addition  to  the  above  treatment,  four  drops  of  spirits  of  turpen- 
tine every  six  hours.  She  did  well,  all  bad  symptoms  disap- 
pearing and  urine  clearing  up  till  the  fourth  day,  when  I  thought 
it  best  to  begin  the  administration  of  quinine,  and  accordingly 
gave  her  three  grains  every  four  hours  all  that  day.  That  night 
I  received  a  message  that  she  was  having  hemorrhages  in  larger 
amounts  than  any  time  previous.  I  went  and  found  her  very 
feeble  and  much  agitated.  I  directed  the  quinine  to  be  discon- 
tinued, and  stimulants  in  the  form  of  whiskey  to  be  adminis- 
tered every  half  hour.  The  hemorrhages  began  to  get  smaller 
in  amount  and  less  frequent,  and  the  next  day  she  was  doing 
fairly  well  again.  Four  days  after  this  she  had  gained  strength 
sufficiently,  I  thought,  to  again  stand  the  effects  of  quinine,  and 
began  the  administration  with  the  same  effects  as  detailed  above. 
She,  this  time,  recovered  after  the  quinine  was  stopped.  I  then 
ordered  liq.  potass,  arsenit.  in  doses  of  one  drop  to  be  increased 
one  drop  every  second  day  till  three  drops  were  taken,  and  then 
decreased  and  increased  again  in  the  same  manner,  if  no  bad 
symptoms  presented  themselves.  After  a  few  days,  I  ordered 
a  ferruginous  tonic,  and  she  made  an   uninterrupted   recovery. 

Case  II. — An  adult  male  with  about  the  same  history  and 
symptoms.      I  treated  as  Case  No.  I,  only  leaving  off  the  quinine 


SMITHWICK.-HEMORRHAGIC   FEVER. 

34 

entirely,  in  consequence  of  which,  in  my  mind,  the  hemorrhages 
never  recurred  when  stopped,  and  the  patient  went  on  to  rapid 
recovery. 

In  both  these  cases  I  made  as  thorough  and  minute  examina- 
tions of  the  blood  and  urine  as  I  possibly  could. 

Systematic  microscopical  examinations  were  made  of  the 
blood  every  day,  and  I  found  the  sestivo-autumnal  form  of  the 
malarial  parasite  present  at  all  times,  in  greater  or  less  numbers. 
When  the  attacks  were  at  their  height  the  blood  fairly  swarmed 
with  the  parasites,  but  their  numbers  diminished  as  the  patients 
improved,  though  they  did  rot  entirely  disappear  till  convales- 
cense  was  nigh  at  end.  The  presence  of  any  other  form  of  the 
parasite  I  could  not  at  any  time  make  out.  When  the  hemor- 
rhage recurred  in  Case  I,  the  parasites  were  not  perceptibly  in- 
creased in  numbers  either  in  the  blood  or  urine,  and  I  can  not 
think  that  the  hemorrhages  were  increased  by  a  reinfection  or  a 
reinforcement  of  the  parasites;  but  I  do  think  they  were  caused 
by  some  action  of  the  quinine  administered.  How  near  I  am 
right  I  do  not  know,  but  this  is  my  conclusion  after  watching 
that  case  and  a  number  ot  other  in  which  quinine  had  been  ad- 
ministered. 

The  examination  of  the  urine  showed  disintegrated  red  blood 
cells,  and  on  one  or  two  occasions  intact  red  blood  cells  were 
observed,  though  they  were  few  in  number.  Casts  were  present 
to  some  extent  at  all  times  till  improvement  was  well  along, 
when  they  entirely  disappeared.  A  few  parasites  of  the  aestivo- 
autumnal  form  were  observed  from  time  to  time,  but  at  no  time 
were  they  abundant.  A  few  were  observed  in  the  intact  cor- 
puscles that  were  noticed  in  the  urine.  Slight  traces  ot  albumin 
were  found  throughout  the  whole  course  of  the  disease,  which 
was  slow  to  disappear. 

The  diet  of  both  patients  was  milk,  principally,  either  butter 
or  skimmed  being  used.  They  drank  lemonade  and  boiled 
water. 

I  give  these  remai  ks  and  observations  for  what  they  are  worth, 
and  will  be  glad  at  any  time,  to  assist  a  worthy  brother  in  the 
profession,  if  I  can. 


Society  1Report0. 


RICHMOND  ACADEMY  OF  MEDICINE  AND  SURGERY. 


REGULAR  meeting  held  December  21,  1897.  Dr.  J  .N.  Up- 
shur (President),  in  the  chair.  Dr.  Mark  W.  Peyser,  Sec- 
retary and  Reporter. 
Election  of  officers  for  the  year  1898,  resulted  as  follows:  Dr. 
M.  D.  Hoge,  Jr.,  President;  Dr.  E.  C.  Levy,  First  Vice-Presi- 
dent; Dr.  A.  L.  Wellford,  Second  Vice-President;  Dr.  A.  C. 
Palmer,  Third  Vice-President;  Dr.  Mark  W.  Peyser,  Secretary 
and  Reporter;  Dr.  W.  H.  Parker,  Assistant  Secretary ;  Dr.  R. 
B.  Teusler,  Treasurer;  Dr.  R.  W.  Nichols,  Librarian. 

REPORTS  OF  CASES. 
VOMITING   OF   BLOOD   BY    ONE-DAV-OLD  INFANT. 

The  President  reported  a  case  the  like  of  which,  he  said,  he 
had  never  seen  before.  On  Sunday  afternoon,  19th,  he  deliv- 
ered a  primipara,  after  an  easy  labor,  of  a  girl  baby  weighing 
six  pounds.  It  nursed  heartily  and  there  was  no  indication  of 
trouble  for  twenty-four  hours,  when  it  threw  up  blood  and 
colostrum.  The  history  of  the  parents  unexceptional.  Within  a 
few  hours  of  vomiting,  there  were  frequent  operation  scontaining 
large  amounts  of  meconium  and  blood.  The  skin  and  mucous 
membrane  were  pallid,  the  fontanelles  depressed,  and  sutures 
prominent.  He  was  at  a  loss  to  account  for  the  haemorrhage; 
but  his  idea  was  that  there  existed  engorgement  of  the  liver  with 
congestion  of  the  portal  system  and  hyperaemia  of  the  stomach 
and  bowels.  Thus  he  prescribed  calomel,  two  grains,  and 
chalk,  one  grain,  divided  into  ten  powders,  one  powder  given 
every  hour.  This  afternoon  (21st),  the  child  was  getting  under 
the  influence  of  the  calomel,  and  as  a  result,  there  was  less 
blood  in  the  last  three  operations,  and  the  child  was  progress- 
ing very  satisfactorily.  After  mentioning  the  case  to  several 
medical  friends  who  had  never  seen  or  heard  of  such  a  case,  he 
consulted  the  American  Text  Book  on  Children,  and  found  reports 
of  several  cases  with  suggestion  of  just  such  treatment  as  he 
had  given. 


g  SOCIETY  KEPORTS. 

FULMINANT    APPENDICITIS 

Dr.  George  Ross  said  that  in  the  past  week,  he  had  had  the 
only  case  oi fulminating  appendicitis,  he  had  ever  seen.  The  patient 
was  a  man,  age  21,  of  feeble  physique,  night  operator  of  the 
long-distance  telephone.  He  had  had  bronchitis  and  recovered. 
On  the  night  before  his  death,  beseemed  perfectly  well.  When 
seen  at  3  P.  M.,  there  was  a  temperature  of  102.5°;  pulse,  130; 
and  marked  tenderness.  At  night,  temperature  was  101.5°, 
pain  diminished,  but  general  condition  unfavorable.  A  con- 
sultation was  held,  with  the  result  that  the  patient  was  taken  to 
Virginia  Hospital,  but  died  before  he  could  be  placed  on  the 
table. 

Dr.  Ed.  McGuire  said  he  had  seen  a  large  number  of  cases  of 
appendicitis,  and  had  reached  the  conclusion  that  no  single 
symptom  could  be  relied  upon  to  determine  an  operation.  In 
the  case  of  Dr.  Neblett,  there  was  suppurative  peritonitis  with 
a  necrotic  appendix.  He  had  been  improving,  and  on  the  even- 
ing of  his  death,  was  thought  to  be  out  of  danger;  but  he  was 
seized  with  convulsions,  and  in  three  hours  was  dead.  The 
urine  was  loaded  with  albumen. 

Last  Monday  morning,  he  saw  a  young  man  who  had  had  a 
cramp  the  night  before  while  on  the  train.  There  was  a  regu- 
lar pulse  and  no  fever.  On  the  right  side  was  a  little  tender- 
ness. The  bowels  were  free,  but  he  had  vomited.  Thinking  it 
was  cholera  morbus,  calomel  was  prescribed.  In  the  afternoon, 
upon  making  a  second  visit,  was  found  increased  tenderness, 
with  a  temperature  of  ioo4°.  Appendicitis  was  diagnosed,  and 
the  patient  taken  to  Virginia  Hospital  and  operated  upon  the 
next  day  at  1  o'clock.  A  necrotic  appendix  was  found.  Re- 
covery ensued. 

Dr.  McGuire  sa.\<5i,  in  conclusion,  that  he  had  again  and  again 
seen  cases  where  the  symptoms  were  slight,  but  the  course  of 
the  disease  bad.  He  thought  if  all  cases  could  be  operated  up- 
on within  twelve  hours,  mortality  would  be  reduced  to  i  percent. 

OCCLUSION  OF    OPENING    INTO    CAECUM    POSSIBLE    CAUSE    OF    APPEN- 
DICULAR   ABSCESS    OF    FULMINANT    APPENDICITIS. 

D.  W.  T.  Qppenhimer  observed  that  in  the  fulminating  form 
the  appendix  was  always  occluded  next  to  the  ccECum,  distention  resul- 
ting from  accumulation  of  gas  or  pus.     In  a  number  of  cases, 


SOCIETY  REPOETS. 


37 


the  appendix  could  be  cut  off  and  no  opening  seen  ;  therefore, 
he  believed  that  in  these  the  organ  could  be  taken  away  close  to 
the  caecum,  no  escape  of  pus  resulting  because  of  the  agglutina- 
tion. It  was  possible  that  a  ligature  was  not  necessary  in  these 
instances,  and  not  applying  one  would  prevent  secondary  haemor- 
rhage. He  had  observed  cases  without  fecal  fistula,  in  which 
the  appendix  had  sloughed  off  and  was  floating  in  pus.  Never 
having  seen  the  point  mentioned  in  any  literatnre,  he  was  of  the 
opinion  that  it  and  the  question  of  ligature  should  be  inves- 
tigated. 

Dr.  Hugh  M.  Taylor.,  thought  appendicitis  capable  of  furnish- 
ing a  greater  number  of  surgical  surprises  than  any  disease  with 
which  he  was  familiar;  and  while  it  had  claimed  the  lion's  share 
of  professional  thought  for  the  past  ten  years,  we  were  only 
upon  the  threshold  of  knowledge  as  reguards  many  of  its  most 
important  phases.  Its  etiology  was  an  open  question:  a  termi- 
nal circulatory  supply;  a  short  mesentery;  a  structure  of  feeble 
resistance;  an  estuary  in  the  fecal  current  often  blocked;  and  an 
ever-present  micro  organism  were  credited  as  etiological  fac- 
tors; but  we  must  ascertain  more  of  its  causation  before  we 
could  hope  to  do  anything  in  the  way  of  preventing  it.  Ideal 
surgery  was,  of  course,  preventive  surgery,  and  it  was  to  be 
hoped  that  future  evolution  of  the  subject  might  attain  such  an 
end.  Individual  and  collective  professional  opinion  as  to  ap- 
pendicitis— its  etiology,  symptoms  and  treatment — presents  a 
succession  of  acrobatic  changes.  He  thought  he  was  correct  in 
claiming  that  many  more  conservatives  were  becoming  radical  in 
their  views  as  to  the  importance  of  early  operative  interference, 
and  thorough  work  whenever  the  condition  of  the  patient  war- 
ranted. His  experience  fully  sustained  the  conclusion  that  an 
early  resort  to  operation  found  the  patient  sufficiently  strong  to 
endure  complete  work — /.  <?.,  strong  enough  to  bear  the  prolon- 
ged anaesthesia,  removal  of  the  appendix  and  pus  cavity,  unmat- 
ting  of  the  bowels,  resection  of  infected  omentum,  etc.  He 
would  impress  the  idea  that  an  early  operation  was  conserva- 
tive in  that  it  sought  to  prevent  pus  collections  and  adhesions 
of  the  appendix,  bowels  and  omentum,  and  the  serious  compli- 
cation of  septic,  purulent  or  fibrino-plastic  peritonitis.  He  con- 
tended that  at  some  time  in   the  history  of  every  case  of  appen- 


,8  SOCIETY  REPORTS. 

dicitis,  it  was  entirely  a  local  phlegmon,  and  this  was  the  elec- 
tive period  for  operative  interference. 

Some  of  his  friends,  medical  John  Jaspers,  rarely  saw  cases 
of  appendicitis,  and  never  met  with  cases  calling  for  operations. 
When  a  practitioner  of  experience  told  him  he  never  had  torn 
perinei,  he  felt  like  telling  him  "Your  eye-sight  is  defective," 
or  "You  do  not  lift  up  the  sheet  to  look."  So  when  a  man 
told  him  he  never  met  with  cases  of  appendicitis,  he  was  temp- 
ted to  urge  him  to  study  its  symptoms,  and  was  almost  willing 
to  promise  him  acquaintance  with  a  surprising  number  of  cases. 

Typical  appendicitis  should  be  as  easy  to  diagnose  as  typical 
pneumonia,  typical  typhoid  fever,  etc. ;  but  unfortunately,  we 
met  with  a  good  many  cases  which  were  atypical,  and  in  this 
class,  the  differential  diagnosis  was  not  always  easy.  Three 
conditions  in  the  right  half  of  the  abdonaen  and  pelvis  notably, 
presented  symptoms  simulating  some  one  of  the  clinical  types  of 
appendicitis.  He  alluded  tojgall-tract  and  tubo-ovarian  inflam- 
mations and  displaced  right  kidney  with  renal  oi  Dietle's  crisis. 
The  diagnosis  was,  of  course,  earsier  in  men,  inasmuch  as  cho- 
lelithiasis and  its  consequences — cholangitis,  cholecystitis,  empy- 
ema of  the  gall-bladder  and  gall-tract  colic  were  so  much  more 
frequent  in  women.  Displaced  kidney  and  its  effects  were  like- 
wise more  common  in  women,  and  usually  occurred  on  the  right 
side.  Inflammation  and  suppuration  from  tubo-ovarian  disease, 
and  that  incident  to  appendicitis,  might  present  symptoms  in 
common,  but,  usually,  the  differentiation  could  be  made.  The 
intimate  lymphatic  and  vascular  connection  between  the  right 
broad  ligament  and  the  meso  appendix  should  be  borne  in  mind, 
as  it  explained  the  frequent  co-existence  of  appendicitis  and 
right  tubal  inflammation.  Conditions  less  frequently  and  less 
positively,  obscuring  diagnosis  of  appendicitis  were  lyphoid 
fever,  ileus,  intestinal  indigestion,  tubal  gestation,  gastric  ulcer, 
hysteria,  etc.  He  had  at  the  present  time,  two  cases  of  phan- 
tom appendicitis.  In  both,  he  was  satisfied  that  the  morbid 
condition  existed  only  in  the  nervous  system.  Both  patients 
were  able  to  simulate  many  of  the  symptoms  of  appendicitis, 
as  localized  pain,  muscular  rigidity,  etc.  He  was  obliged  to 
ansesthetize  one  in  order  to  satisfy  himself  as  to  diagnosis,  while 
the  other  spent  sleepless  nights  and  anxious  days,  and  upon  one 


SOCIETY  REPORTS.  39 

occasion  implored   him  to  operate,  so  that  he   need  not  endure 
another  such  night  of  agony. 

Dr.  Ed.  McGuire  said  if  Dr.  Oppenhimer's  suggestions  were 
followed, there  would  be  liability  to  secondary  infection.  He 
had  seen  fecal  matter  in  more  than  one  instance  in  such  cases. 


NEW  YORK  ACADEMY  OF  MEDICINE. 

SECTION  IN  ORTHOPAEDIC  SURGERY  MEETING  OF  NOVEMBER  I9,    1897. 


DISEASES  AND  DEFORMITY  OF  THE  TIBIA. 

DR.  S.  KETCH  presented  a  patient  with  an  unusual  defor- 
mity of  5  years  duration.  The  patient  was  a  girl  12  years 
old.  He  had  seen  her  for  the  first  time  one  week  ago. 
There  was  anterior  bowing  of  the  right  tibia  and  some  eversion 
of  the  foot.  The  bone  was  3.  inches  longer  than  that  of  the 
well  leg  and  greatly  thickened.  The  circumference  of  the  leg 
was  x-Yn  inches  larger  than  on  the  well  side.  The  child's  gen- 
eral condition  was  poor,  the  result  probably  of  pain,  which  had 
been  a  feature  of  the  history.  The  skiagraph  showed  a  thickened 
tibia  with  some  irregularities  in  the  enlargement  and  an  almost 
complete  disappearance  of  the  epiphyseal  line  due  to  pressure. 
He  had  traced  cases  resembling  this  in  many  features  to  syphi- 
lis, but  here  there  were  no  signs  of  infection  and  no  history  of 
transmission. 

Dr.  W.  R.  Townsend  s>di\d  that  he  had  seen  a  somewhat  simi- 
lar case  in  which  the  extra  heat  of  the  limb  had  lead  to  a  diag- 
nosis of  osteitis.  The  diagnosis  was  wrong  however  as,  at 
the  end  of  5  years,  the  bone  was  found  to  be  sarcomatous  and 
amputation  was  done.  He  thought  that  the  question  of  sarco- 
ma should  not  be  overlooked  in  considering  the  treatment  of 
the  present  case.  The  remarkable  deformity  of  the  bone  had 
some  resemblance  to  the  bowing  of  a  syphilitic  tibia,  but  it  was 
no'  the  "lame  de  sabre"  described  by  Fournier. 

Dr.  H.  L.  Taylor  said  that  the  strong  anterior  curvature  of 
the  tibia,  the  enlargement  throughout  the  shaft,  the  slight 
nodes  on  the  surface  and  the  elongation  of  the  bone  pointed  to 
syphilitic  osteitis. 

Dr  y.  l^eschner  had  noticed   that  the  swelling  and  tenderness 


SOCIETY  REPORTS. 
40 

were  more  marked  on  the  anterior  aspect  of  the  bone  where 
there  was  probably  pus.  These  signs  and  the  localized  heat  in- 
dicates an  inflammatory  action  and  led  him  to  believe  that  there 
was  necrosis  and  that  a  sequestrum  had  produced  the  thicken- 
ing and  enlargement. 

Dr.  R^  Whitman  said  that  the  skiagram  showed  that  the  en- 
tire bone  was  involved.  He;  did  not  think  it  was  sarcoma,  but 
rather  a  case  of  diffuse  osteitis  which  might  have  been  of  syph- 
ilitic origin.  There  might  also  have  been  a  fragment  of  necro- 
sed bone  within  the  shaft  which  kept  up  the  chronic  inflamma- 
tion with  continuous  enlargement  of  the  bone. 

Dr.  V.  P.  Gibney  said  that  he  would  treat  the  case  as  one  of 
abscess  of  the  tibia.  Opening  the  medullary  canal  would  pro- 
bably reveal  several  abscesses.  In  any  case  it  would  not  do 
any  harm  to  operate  in  this  way  even  if  the  case  were  one  of 
sarcoma.  He  had  operated  for  multiple  abscess  of  the  tibia  in 
a  young  woman  and  had  planted  decalcified  ox  bone  in  the 
trough-like  cavity.  Some  of  it  remained  and  some  did  not,  and 
other  operations  had  to  be  done.  Since  the  last  she  had  been 
perfectly  well  and  was  living  out  at  service. 

Dr.  Ketch  said  he  was  disinclined  to  think  that  his  patient 
had  sarcoma.  This,  as  well  as  multiple  abscess,  would  have 
caused  more  local  and  general  disturbance.  He  believed  that  a 
sequestrum  was  present.  Anti-sypilitic  medication  would  be 
thoroughly  tried  and  after  that  it  was  probable  that  the  bone 
would  be  operated  on. 

A    CASE    OF    GENO-VALGUM. 

Dr.  R.  H.  Sayre  presented  a  patient,  a  boy  16  years  old, 
who,  while  carrying  heavy  loads  in  a  bakery,  6  months  ago,  be- 
gan to  have  double  genu-valgum,  the  result  of  adolescent  rick- 
ets, and  a  failure  of  the  bone  of  the  leg  to  sustain  the  weight. 
Three  months  ago  the  limbs  were  put  in  plaster  of  Paris  and  the 
boy  was  kept  in  bed  for  two  months.  To  correct  the  defor- 
mity a  circular  cut  was  made  in  the  plaster  of  Paris  around 
the  knee  and  a  wedge  of  wood  was  inserted  on  the  outer  side. 
In  a  week  or  so  the  knee  was  straightened  still  further  and  a 
larger  wecge  was  inserted.  At  the  end  of  two  months  when 
the  splint  was  removed  and  the  boy  began  to  walk  again,  there 
was  a  slight  transient  synovitis.     To   improve  his  general   con- 


SOCIETY  REPORTS.  4 1 

dition  strichnia  had  been  given  and  the  elixir  phorphori  of  the 
national  formulary.  The  result  of  the  treatment  was  that  the 
limbs  were  very  nearly  straight.  As  there  remains  some  relax- 
ation of  the  joints,  he  should  have  braces  to  prevent  lateral  mo- 
tion during  convalescence. 

AN    OPERATION    FOR    SLIPPING    PATELLA. 

Dr.  Whitman  presented  a  boy  13  years  old  on  whom  he  had 
operated  16  months  ago  for  slipping  of  the  right  patella.  The 
capsule  had  been  divided  on  the  outer  side  and  considerable 
difficulty  had  been  found  in  reducing  the  dislocation  on  account 
of  the  contraction  of  the  tissues.  A  tuck  was  taken  in  the  cap- 
sule on  the  inner  side.  The  patella  was  now  over  the  external 
condyle.  When  he  left  the  hospital  it  had  been  in  the  median 
line.  For  a  time  he  had  worn  a  knee-cap  as  directed,  which  he 
had  long  ago  discarded.  This  case  was  not  presented  as  a  fair 
test  of  the  operation,  as  the  dislocation  was  but  part  of  the  dis- 
ability and  deformity  attending  hemiplegic  contraction  of  the 
right  side  of  the  body.  It  had,  however,  relieved  pain  and 
discomfort. 

Dr.  Gibney  said  that  it  was  still  a  question  what  is  the  best 
treatment  for  slipping  patella.  He  had  transplanted  a  frag- 
ment of  the  tibia  with  the  insertion  of  the  ligamentum  patellae 
in  a  girl  14  years  old.  Union  in  the  new  position  was  secured 
and  the  limb  was  put  up  in  plaster  of  Paris.  In  spite  of  a  little 
suppuration,  the  recovery  was  good.  The  ultimate  result,  how- 
ever, was  in  doubt,  as  the  patient  was  lost  sight  of. 

In  another  young  woman  the  slipping  had  occurred  repeated- 
ly, followed  sometimes  by  acute  inflammation.  A  splint  had 
been  applied  and  she  was  wearing  it  still  to  keep  the  patella  in 
place.  In  a  boy  of  4  years  the  slipping  patella  had  been  easily 
reduced  and  it  is  probable  that  massage  and  the  growth  and 
development  of  the  muscular  fibres  will  be  sufficient  to  remove 
the  trouble. 

KYPHOSIS  OF  UNCERTAIN  ORIGIN, 

Dr.  Townsend  presented  a  patient  with  marked  kyphosis  in 
the  dorsal  region  and  slight  lateral  curvature.  The  patient  was 
a  man  24  years  old,  a  clerk  by  occupation.  He  had  had  slight 
pains  in  the  back  for  8  years,  but  within  the  past  year  the  pain 
had  increased   and  was   accompanied   by  shortness  of    breath. 


-2  SOCIETY  REPORTS. 

The  diagnosis  had  not  been  fully  made.  It  was  possibly  a  case 
n  which  lateral  curvature  was  the  chief  cause  of  the  deformity 
and  symptoms,  or  it  might  bean  instance  of  exaggerated  round 
shoulders,  or  vertebral  caries  might  have  been  the  origin  of  the 
trouble. 

Dr.  Gibney  said  he  saw  no  indication  of  osteitis  or  tubercular 
disease  of  the  spine.  There  was  a  little  lateral  curvature  and 
an  exaggerated  anterior  curve. 

Dr.  Ketch  said  that  the  case  was  one  which  had  not  followed 
the  ordinary  course  of  lateral  curvature.  The  general  kypho- 
sis reminded  him  of  senile  curvature  which,  however,  rarely  oc- 
curred at  the  age  of  the  patient.  The  man  had  said  that  the 
pain  had  been  so  severe  as  to  require  the  use  of  mustard  plas- 
ters. It  had  radiated  around  from  the  back  to  the  front  under 
the  nipples.  He  had  never  met  a  case  of  lateral  curvature  in 
which  there  was  pain  at  the  terminal  end  of  the  nerve.  He 
thought  this  was  the  pain  of  an  inflammatory  lesion  and  that 
the  trouble  was  antero-posterior  rather  than  lateral  and  was 
getting  worse.  He  would  treat  the  patient  for  an  inflamma- 
tory affection  and  would  advise  a  certain  amount  of  rest  for  the 
spine. 

Dr.  Teschner  thought  that  the  curvature  was  antero-posterior 
and  that  the  condition  was  neither  tubercular,  rheumatic  nor 
osteitic  and  that  the  pain  was  not  necessarily  due  to  nerve  pres- 
sure, but  rather  to  the  immobility  of  the  spine,  or  it  might  be 
due  to  indigestion.  He  would  increase  the  mobility  by  two  or 
three  weeks  of  gymnastics.  He  thought  that  the  patient  should 
not  be  put  on  any  kind  of  retentive  apparatus  which  would 
hold  the  spine  immovable.  Considerable  pain  was  present  in 
some  cases,  even  when  the  curvature  was  not  marked.  This 
pain  was  generally  due  to  a  relaxed  condition  and  not  to  nerve 
pressure.  It  was  a  muscular  pain  like  that  caused  by  stretching 
a  muscle,  analogous  to  that  of  muscular  rheumatism.  This 
could  be  relieved  by  exercising  the  muscle  vigorously,  produc- 
ing a  little  more  pain,  and  repeating  the  same  thing  the  next 
day;  the  pain  will  then  disappear.  These  cases  could  be  cured 
in  from  48  to  74  hours  if  relief  from  pain  was  considered  a  cure. 
Some  lateral  curvature  patients  complain  of  pain  only  on  exe- 
cuting certain  movements,  as  for  instance,  writing  or  violin 
playing,  etc.     A  patient  had  formerly  been    able   to  play  the 


SOCIETY  REPORTS.  a^ 

violin  from  2  to  3  hours  without  inconvenience.  When  lateral 
curvature  appeared,  she  could  not  play  for  15  minutes  without 
pain,  but  after  a  short  treatment  she  could  play  as  formerly. 

Dr.  A.  B.  Judson  thought  that  the  case  was  one  of  lateral  curva 
tare  in  which  the  curve  in  the  line  of  the  spinous  processes  was 
slight,  while  the  curve  in  the  bodies  of  the  vertebrae  was  proba- 
bly exaggerated.  This  would  have  the  same  effect  on  the  trunk 
as  if  it  were  compressed  vertically.  The  trunk  was  shortened 
and  the  result  was  bulging  of  the  crest  walls  and  kyphosis  with 
a  sharp  anterior  curvature  in  the  lumbar  spine.  In  a  question 
of  diagnosis,  he  thought  that  pain  and  other  subjective  symp- 
toms were  less  important  than  the  objective  signs.  He  would 
treat  the  patient  for  lateral  curvature  by  appropriate  exercises 
and  attitudes  for  expanding  the  contents  of  the  chest  and  the 
avoidance  of  fatigue. 

Dr.  Taylor  thought  that  the  case  was  one  of  lateral  curva- 
ture with  more  than  the  usu  il  pain  and  with  the  exaggerated 
roundness  of  the  shoulders  sometimes  found  in  people  whose 
weakness  induced  postural  deformity. 

Dr.  T.  H.  Manley  said  that  the  history  of  the  case  pointed  to 
some  special  constitutional  condition  which  had  caused  the  de- 
flection of  the  spine.  He  thought  that  the  question  of  syphilis 
should  be  considered.  There  were  no  evidences  of  a  tubercular 
condition,  but  he  thought  thai  there  was  a  rachitic  element  in 
the  case.  He  would  combine  local,  mechanical  support  with 
constitutional  treatment  by  the  administration  of  acids  or  iron. 

UNUSUAL    DISLOCATION    OF    THE    TIBIA. 

Dr.  Taylor  presented  a  patient  with  unusual  deformity  and 
disability  of  the  right  knee.  The  patient  was  a  woman,  23 
years  old.  The  trouble  had  begun  when  she  was  9  months  old 
with  redness  and  swelling,  and  the  knee  became  flexed  and  its 
motions  limited.  When  she  was  10  years  old  the  was  injured  by 
a  fall  and  has  been  deformed  as  at  present  ever  since.  There 
has  been  no  abscess  and  no  cutting  operation  has  been  perform- 
ed. There  is  complete  dislocation  of  the  head  of  the  tibia  back- 
ward and  abnormal  lateral  mobility.  The  bones  of  the  knee 
are  small  and  there  is  about  i-^^  in.  of  shortening  of  the  limb. 
There  is  considerable  voluntary  motion  and  she  can  walk  for  a 
few  minutes  without  her  brace. 


SOCIETY  REPORTS. 
44 

Dr.  Townsend  had  seen  a  similar  case,  but  less  marked,  in 
which  the  deformity  was  due  to  an  inflammatory  lesion  without 
any  destruction  of  the  bone. 

Dr.  Gibney  recalled  cases  of  supposed  congenital  dislocation 
of  the  hip  in  which  operation  had  revealed  the  results  of  an  in- 
flammatory process  so  extensive  that  the  head  of  the  bone  was 
well  nigh  gone.  He  thought  the  present  case  might  have  had 
a  similar  origin. 

Dr.  Manley  thought  that  the  condition  of  the  patient's  knee 
was  due  to  some  pathological  process  and  not  to  traumatism. 
He  said  that  the  case  was  a  proper  one  for  resection  of  the  fibula 
and  tibia.  He  was  perfectly  aware  that  the  acuteness  of  the 
operative  furor  had  swept  over  and  that  we  are  getting  back  to 
more  salutary  conservatism,  but  this  seemed  to  be  an  ideal 
case  for  operation. 

Dr.  Taylor  said  that  the  patient  had  declined  operative  treat- 
ment and  he  intended  to  continue  giving  to  the  limb  mechani- 
cal support  by  means  of  a  Thomas  (caliper)  splint  attached  to 
the  shoe,  instead  of  extending  below  it.  He  thought  that  the 
small  size  of  the  bone  was  due  to  lack  of  development  rather 
than  to  destruction  of  the  bone  and  that  it  was  very  improbable 
that  this  condition  was  produced  by  a  fall  in  a  healthy  limb. 
There  had  been  some  pathological  process  from  infancy  which 
probably  left  subluxation  and  flexoin,  as  usually  happens  in 
chronic  inflammation  of  the  knee,  and  the  fall  at  lo  years  of  age 
might  have  greatly  increased  the  trouble.  He  had  seen  a  patient 
in  whom  a  similar  condition  had  been  caused  by  traction  ap- 
plied in  the  treatment  of  hip-joint  disease.  The  hip  was  cured 
but  the  knee  was  weakened  so  that  the  tibia  just  hung  on  the 
posterior  edge  of  the  condyles. 


translations  an^  jforcign  IReviews. 


IN   CHARGE  OF 

Richard  H.  Whitehead,   M.D.,   Chapel  Hill,   N.    C. 


A  NEW  TREATMENT  OF  POTT'S  DISEASE. 


THE  treatment  of  spinal  caries  has  always  been,  at  best, 
very  unsatisfactory.  In  cases  at  all  extensive  the  most 
the  surgeon  expected  was  recovery  with  ankylosis,  the 
patients  being  hunchbacks  for  the  remainder  of  their  lives. 
About  a  year  ago  a  young  surgeon  to  a  childrens'  hospital  at 
Bercksurmer,  Calot,  {Archives  Provinciales  de  Chirurgie,  1897 
No.  2.)  aroused  great  interest  by  proposing  to  treat  this  disease 
by  the  methods  used  to  overcome  deformity  in  spinal  disloca- 
tions— i.e.,  by  rapid  and  forcible  reduction  under  extension  and 
counter-extension  and  subsequent  application  of  a  plaster  jacket. 
The  extension  is  effected  by  assistants  who  pull  upon  the  head 
and  extremities  of  the  patient,  while  the  operator  passes  with 
his  hand  upon  the  curvature  until  the  deformity  disappears, 
when  a  plaster  jacket  is  applied  from  head  to  hips.  The  whole 
operatic.n  is  done  under  complete  anaesthesia.  It  is  said  that  in 
most  cases  reduction  is  effected  with  surprising  ease.  The  sub- 
sequent treatment  is  that  usual  in  these  cases  with  especial  at- 
tention to  hygienic  measures.  Calot  claims  that  by  this  opera- 
tion the  patients  recover  without  deformity,  the  cavity  neces- 
sarily formed  between  the  bodies  of  the  vertebra  where  the 
curvature  is  reduced  being  filled  up  by  firm  new  bone.  That 
this  actually  occurs  he  determines  by  the  X-ray,  and  the  patients 
are  not  allowed  to  dispense  with  the  plaster  corset  until  this 
new  bone  formation  is  so  confirmed.  He  reported  a  small 
number  of  cases  in  support  of  his  views.  This  startling  propo- 
sition was  naturally  received  with  distrust,  for  it  has  been 
handed  down  from  generation  to  generation  of  surgeons  that 
Pott's  disase  is  a  thing  to  be  treated  with  the  utmost  respect, 
and  many  were  inclined  to  regard  Calot  as  one  of  the  "fools" 
who  "rush  in  where  angels  fear  to  tread. "  And  with  good 
reasons;  for  a  number  of  objections  immediately  suggest  them- 
selves.    These    have    been    especially    emphasized    by    Lorenz 


.g  TRANSLATIONS  AND  FOREIGN  REVIEWS 

{Deutscher  Med.  Wochenschrift,  1897,  No.  35),  and  by  Menard 
{La  Semaine  Medicale,  1897,  No.  23),  likewise  of  Bercksurmer. 
Thereotically  it  would  seem  that  rupture  of  the  membranes,  in- 
jury to  the  cord,  rupture  of  abscesses  with  extension  of  the  dis- 
ease to  surrounding  parts,  or  general  dissemination  of  tubercle, 
are  by  no  means  imaginary  dangers,  and  cases  have  been  re- 
ported where  one  or  more  of  these  accidents  undoubtedly  oc- 
curred. However,  at  the  last  International  Congress  Calot  re- 
ported upon  204  cases,  only  two  of  which  died  as  the  result  of 
the  operation.  Other  surgeons  reported  smaller  series  without 
any  accidents.  So  that  surgeons  of  such  reputation  as  Pean 
and  Broca  express  the  opinion  that  the  operation  can  be  done 
easily  and  without  danger  in  properly  selected  cases.  They 
would  exclude  all  cases  of  long  standing  and  those  complicated 
by  abscess  or  tuberculosis  of  other  organs.  But  if  we  grant 
that  the  operation  is  without  danger  in  suitable  cases  the  ques- 
tion of  the  permanency  of  results  comes  up,  and  upon  the 
answer  to  this  question  the  fate  of  the  procedure  depends. 
As  stated  beiore,  Calot  claimed  that  the  cavity  between  the  dis- 
eased vertebral  bodies,  which  is  necessarily  formed  when  the 
deformity  is  corrected,  is  filled  by  a  new  growth  of  bone  firmly 
ankylosing  the  adjacent  bones.  This  is  entirely  contrary  to 
what  we  would  be  led  to  expect  from  our  knowledge  of  the 
tubercular  process  in  all  other  points,  where  the  tendency  to 
generation  of  new  bone  is  slight  even  after  entire  cessation  of 
the  disease.  Autopsies  upon  children  dead  of  Pott's  disease 
have  shown  that  the  adjacent  vertebrae  are  often  separated  from 
two  to  four  inches  where  the  deformity  is  reduced.  It  cannot 
yet  be  regarded  as  proven  that  such  large  cavities  as  these  will 
be  firmly  filled  by  new  bone,  and  if  partially  filled  the  deformity 
must  recur.  Calot  reports  that  twenty  of  his  cases  are  now 
walking  erect.  It  is  a  question  for  time  to  settle,  and  another 
year  or  two  will  show  whether  or  not  a  great  advance  has  beea 
made  in  the  treatment  of  tuberculosis  of  the  vertebral  column. 


NORTH  CAROLINA  MEDICAL  JOURNAL, 


ROBERT  D.  JEWETT,  M.D.,  Editor. 


DEPARTMENT  EDITORS. 
(      H.  T.  Bahnson,  M.D.,  Salem,  N.  C. 
SURGERY:     \     R.  L.  Gibbon,  M.D.,  Charlotte,  N.  C. 

{     J.  Howell  Way,  M.D.,  Waynesville,  N.  C. 

NERVOUS  DISEASES:— J.  Allison  Hodges,  M.D.,  Richmond,  Va. 
PRACTICE  OF  MEDICINE.  |   S.  Vestry  Battle,  M.D.,  U.  S.  N., 

r^TjarpTi^rrRTnQ.      3     George  G.  Thomas,  M.D.,  Wilmington,  N.  C. 
OBbiii^iKiUb.      j     ^  L  Payne,  M.D.,  Norfolk,  Va. 

(      H.  S.  LOTT,  M.D.,  Winston.  N.  C. 
GYNECOLOGY:     \     J.  W.  Long,  M.D.,  Salisbury,  N.  C. 
(     H.  A.  Royster,  M,D.,  Raleigh,  N.  C. 

PATHOLOGY:— Albert  Anderson,  M.D.,  Wilson,  N.  C. 
TRANSLATION  AND  FOREIGN  REVIEWS: 
Richard  H.  Whitehead,  M.  D.  ,  Chapel  Hill,  N.  C 

This  Journal  is  published  on  the  fifth  and  twentieth  of  each  month,  and 
any  subscriber  tailing  to  receive  his  copy  promptly,  is  asked  to  announce  the 
fact  to  this  office. 

Cuts  will  be  provided  for  any  original  communications  (sent  to  this  Jour- 
nal only)  requiring  illustrations,  free  of  cost  to  the  author. 

Secretaries  of  County  Medical  Societies  in  the  Carolinas  are  asked  to 
furnish  condensed  reports  of  their  meetings  to  the  Journal. 

All  communications,  either  of  a  literary  or  business  nature,  should  be 
addressed  to,  and  any  remittances  by  P.  O.  Order,  Draft  or  Registered  Let- 
ter, made  payable  to  Robert  D.  Jewett,  M.D.,  P.  O.  Drawer  825,  Wilming- 
ton, N.  C. 


jeMtoriaL 


OUR  CORPS  OF  COLLABORATORS. 


In  our  last  issue  we  announced  that  we  had  secured  the  assis- 
tance of  some  of  the  most  prominent  members  of  the  profes- 
sion in  our  determination  to  make  the  Journal  better  than  it 
ever  has  been  before.  We  give  at  the  head  of  this  page  a  list 
of  those  gentlemen  who,  during  the  coming  year,  will  review 
the  medical  literature  of  this  country  and  Great   Britain,  with 


g  EDITORIAL. 

the  section  to  which  each  will  devote  his  attention.  A  glance 
at  these  names  will  assure  our  readers  that  the  work  has  been 
entrusted  to  careful  and  capable  hands,  and  they  may  be  sure 
that  when  they  read  the  Journal  they  are  getting  the  latest  and 
the  best  of  everything. 


STATISTICS  OF  ABDOMINAL  SECTION  IN  AMERICA. 


A  letter  upon  this  subject  in  xh.^  Medical  Record  of  January 
8th,  from  Dr.  Lawson  Tait,  makes  very  interesting  reading. 
Dr.  Tait's  letter  is  provoked  by  reading  an  address  of  Dr.  T. 
Gaillard  Thomas,  in  the  annual  report  of  the  Hospital  for 
Women  in  New  York.  In  this  address  Dr.  Thomas  puts  forward 
a  group  of  figures  showing  that  in  seven  large  selected  hospitals 
in  America  the  results  in  abdominal  section  run  from  25  per 
cent,  in  Boston  City  Hospital  down  to  15.03  percent,  in  his 
own  institution.  Of  this  collection  of  statistics  Dr.  Tate  says 
"that  the  whole  thing  is  deplorable  and  must  be  remedied  ;  and 
that  the  mortality  in  the  New  York  Woman's  Hospital  is  'mur- 
derous'  as  Matthews  Duncan  used  to  put  it."  He  refers  to  the 
report  of  the  Birmingham  Hospital  for  Women,  and  selects  the 
year  1893  for  comparison  with  the  New  York  statistics,  because 
this  was  the  first  year  in  which  no  work  was  done  by  himself, 
but  the  bulk  of  it  was  done  by  two  of  his  former  assistants,  and 
also  because  it  was  an  unusually  bad  year.  During  that  year 
there  were  done  176  abdominal  sections  with  a  mortality  of  6.2 
per  cent.  A  series  of  1,350  cases,  from  1884  to  1893,  performed 
almost  entirely  by  Dr.  Savage  and  himself,  gave  a  mortality  of 
5.5  per  cent. 

"During  these  years,"  says  Dr.  Tate,  "I  did  all  my  work  on 
plain  soap  and  water,  having  abandoned  every  trace  of  the 
varying  absurdities  of  Listerism  two  years  before."  In  explan- 
ation of  the  cause  of  his  success  he  says  emphatically,  "the 
absolute  segregation  of  our  patients  and  close  attention  to  every 
detail  constitute  the  whole  of  the  mystery." 

It  is  evident  that  something  is  wrong  in  the  big  hospitals  on 
this  side  the  ocean,  and  this  wrong  should  be  discovered  and 


REVIEW  OF  CURRENT  LITERATURE.  .g 

corrected.  Dr.  Tate  never  loses  an  opportunity  to  cast  a  slur 
at  "Listerism,"  but  we  venture  the  opinion  that  if  he  utterly 
ignored  the  true  principle  of  "Listerism,"  which  is  the  removal 
of  germ  life  from  everything  that  comes  in  contact  with  the 
wound,  he  would  not  be  able  to  present  statistics  showing  a 
mortality  of  5.5  per  cent. 

Lord  Lister  demonstrated  to  the  world  the  importance  of 
"surgical  cleanliness,"  and  whether  the  means  used  be  chemic, 
thermic  or  mechanic  his  teaching  revolutionized  the  art  of 
surgery,  and  his  glory  will  never  fail.  If  Mr.  Tait  would  fol- 
low more  closely  the  antiseptic  and  aseptic  technique  (the  off- 
spring of  "Listerism")  he  might,  with  his  other  admirable 
methods,  reduce  his  death-rate  to  that  "inevitable  mortality" 
which  he  considers  exists. 


IRevlew  of  Current  Xiterature. 


PATHOLOGY. 

in  charge  of 
Albert  Anderson.   M.  D..   Wilson,   N.  C. 


Treatment  of  Diseases. — I  speak  from  experience  and  obser- 
vation in  saying  that  pathology  has  been  too  much  neglected 
by  the  general  practitioner  and  therefore  our  know 
ledge  of  this  important  branch  of  medicine  is  too  lim- 
ited to  have  a  working,  intelligent  basis.  Without  some  knowl- 
edge of  pathology  and  bacteriology  we  have  a  difficult  task  in 
comprehending  the  best  written  articles  in  our  medical  journals. 
Physiology  bears  the  same  relation  to  health  as  pathology  to 
disease.  Suppose  the  average  doctor  knew  as  little  about  phys- 
iology at  the  time  of  his  examination  for  license  as  he  did  of 
pathology  and  bacteriology,  do  you  think  he  would  have  passed? 
Not  at  all.  But  the  demands  for  this  knowledge  is  growing 
and  hence  we  see  all  medical  colleges  putting  their  students  to 
work  on  a  graduated  course  in  histology,  pathology  and  bac- 
teriology and  our  Examining  Board  in  the  future  will  see  to  it 


REVIEW  OF  CURRENT  LITERATURE. 

that  all  applicants  for  license  must  have  a  passing  acquaintance 
with  these  coordinate  branches  that  have  been  made  subordinate 
so  long.  Through  histology  we  see  that  the  cell  is  the  unit  of 
life.  As  long  as  this  unit  is  intact,  well  nourished  and  protected, 
health  is  sure  to  continue.  But  let  this  cellular  life  be  disturbed 
and  then  we  doctors  need  to  know  at  once  the  manner  or  means 
of  disturbance,  and  to  know  correctly,  or  scientifically,  pathol- 
ogy and  its  allied  branches  are  the  only  sources  of  knowledge 
that  will  point  the  way  "toward  the  goal  of  a  rational  and  effec- 
tive therapy."  Of  course  there  are  many  facts  beyond  our  ken 
yet  and  they  to  us  are  mysteries;  but  the  earnest  leaders  to,  or 
seekers  after  truth,  are  blazing  the  way  by  their  researches  and 
classifying  the  mysteries  and  exposing  the  facts.  "Vital  phe- 
nomena" have  covered  too  many  knowable  facts  in  science. 
Let  us  uncover  these  as  far  as  the  power  in  us  lies  by  careful 
study  of  practical  questions  during  this  year — such  as  these: 
The  relation  of  the  cells  of  the  body  to  the  parasites,"  the 
differentiation  of  cells,  alterations  in  serum,  chemiotoxis,  the 
development  of  the  protective  agencies  and  of  antibacterie  sub- 
stances, antitoxins,  immunity  etc.  After  understanding  what 
has  already  been  found  out  about  these  questions,  we  will  then 
try  to  keep  up  with  the  procession. 

Every  physician  is  interested  in  therapeutics,  and  there  are 
mutual  relations  of  pathology  and  therapeutics  that  should  be 
more  generally  known.  Dr.  Robert,  at  the  International  Con- 
gress in  Moscow  last  August,  gave  some  striking  relations  in 
his  paper  on  this  line,  as  follows:  "The  treatment  of  disease 
must  have  for  its  object  a  rearrangement  and  a  rectification  of 
the  disturbed  relations  between  the  cells  and  between  the  differ- 
ent parts  of  each  cell. 

Man,  however,  is  more  than  a  mere  cellular  congeries;  he  is 
a  being  endowed  with  certain  powers  of  resistance  against  in- 
fluences which  threaten  his  well-being  or  very  existence.  Dis- 
ease is  not  dependent  so  directly  upon  the  action  of  any  specific 
micro-organism  as  it  is  upon  an  increased  organic  susceptibility. 
The  mystery  of  disease  is  still  a  mystery,  and  it  has  not  been 
solved  as  yet  by  any  of  the  facts  of  bacteriology  or  pathology. 
One  man  is  affected  by  disease,  another  exposed  to  the  same  in- 
fluences escapes  unscathed.  A  neoplasm  which  is  to-day  benign 
in  its  appearances  may  to-morrow  assume  an  entirely  different 


REVIEW  OF  CURRENT  LITERATURE.  5  i 

aspect  and  take  on  all  the  characters  of  malignancy.  Why  is 
this?  We  cannot  yet  answer.  The  human  organism  reacts  as 
a  whole  to  the  assaults  of  disease,  and  not  by  the  isolated  action 
of  any  individual  cell  or  group  of  cells.  A  specific  infectious 
disease  is  warded  off  or  overcome,  not  by  phagocytosis  alone 
and  not  by  the  special  chemical  properties  of  the  blood  serum 
alone,  but  it  is   conquered    by   the  organism  considered   as   an 

entity.  . 

Our  therapeutic  efforts  must  be  directed  in  a  way  to  furnish 
aid  to  the  entire  organism  in  its  scruggle  against  disease,  to 
strengthen  its  innate  powers  of  resistance,  and  not  merely  to 
fortify  one  of  the  approaches,  leaving  the  others  unguarded. 
The  indications  of  a  rational  treatment  of  disease  are  to  combat 
the  influences  which  have  weakened  the  body  and  so  have  pre- 
disposed it  to  yield  to  the  assaults  of  morbific  agents;  to  sup- 
port and  increase  the  cellular  energies;  to  strengthen  and  stim- 
ulate the  function  of  those  organs  whose  office  it  is  to  preside 
over  metabolism  and  furnish  a  suitable  pabu'um  to  the  rest  of 
the  body;  and  to  protect  the  sensitive  nervous  system,  upon 
whose  integrity  so  much  depends,  against  injury. 

The  so-called  causal  treatment  of  disease  is  not  always  effec- 
tive and  its  advantages  are  often  illusory.  In  our  well-meant 
efforts  to  repress  and  expel  the  causes  of  disease,  we  may  easily 
go  too  far  and  injure  the  already  weakened  organism  in  its  re- 
sistant powers.  It  will  be  of  little  avail  to  annihilate  the  greater 
part  of  the  attacking  force  if  we  thereby  so  weaken  the  defence 
that  it  is  unable  to  resist  the  small  remnant  of  the  enemy  which 
has  escaped  the  action  of  our  destructive  agents. 

We  must  rather  imitate  nature  in  her  therapeutic  efforts, 
which,  after  all,  are  so  often  effective.  The  modern  treatment 
of  diphtheria  by  means  of  injections  of  a  specially  prepared 
antitoxic  serum  is  an  imitation  of  nature  and  is  a  brilliant  ex- 
emplification, the  orator  maintained,  of  the  wisdom  of  this 
course.  The  triumphs  of  orrhotherapy  in  the  management  of 
diphtheria  have  been  great  and  indisputable. 

In  health  as  in  disease  all  the  organs  work  together,  and  it  is 
in  a  disregard  of  this  great  truth  that  the  chief  danger  of  speci- 
alism exists.  The  specialist  is  too  wont  to  consider  the  needs 
of  one  system  or  of  one  organ  in  a  system,  separating  it  from 
the  body  as  a  whole.     This  danger  is  an   imminent  one  at  t 


GYNECOLOGY. 

present  day,  and  it  is  one  against  which  the  true  scientific  phy- 
sician must  never  be  weary  of  protesting.  The  therapist  must 
be  a  man  of  broad  views,  and,  however  small  and  apparently 
circumscribed  is  the  lesion  he  is  called  upon  to  treat,  he  must 
keep  ever  before  him  the  sufferings  of  the  entire  organism,  and 
must  recognize  and  act  upon  the  unquestionable  fact  that  man 
is  a  unit  and  that  we  cannot  hope  to  treat  with  success  a  part 
while  ignoring  the  whole. 

Finally,  the  speaker  said,  the  nervous  system  must  be  strength- 
ened and  enabled  to  act  its  part  in  the  struggle  against  disease. 
This  most  vital  part  of  the  human  organism  is  not  influenced 
by  medication  alone,  but  there  is  here  room  for  that  imponder- 
able therapeutic  agent  which  is  personal  to  each  physician  and 
which  finds  expression  in  his  moral  influence  over  the  patient. 
To  fulfill  in  the  highest  degree  his  divine  mission  the  true  ther- 
apeutist must  be  a  physician  of  the  mind  as  well  as  of  the  body, 
he  must  be  able  to  inspire  in  his  patient  that  confidence  in  him- 
self and  that  hope  in  the  efficacy  of  his  remedies  without  which 
his  best  directed  efforts  will  scarcely  avail. 


GYNECOLOGY. 

IN  CHARGE  OF 

H.   S.    LOTT,   M.  D.,  J.    W.    LONG,   M.   D. 

HUBERT  A.   ROVSTER,   M.    D., 


Post-Operative  Ileus.— Edward  McGuire  (Bi-monthly  Bulletin )in 
a  series  of  seventy-five  abdominal  sections,  done  for  various  patholog- 
ical conditions,  reports  three  very  interesting  cases  of  adynamic  ileus 
with  one  death  from  this  cause,  and  goes  on  to  say:  "Ileus  is  classi- 
fied etiologically  into  adynamic,  dynamic  and  mechanic.  Adynamic, 
as  its  name  implies,  is  that  type  of  ileus  in  which  we  have  an  arrest  of 
intestinal  peristalsis.  It  is  further  divided  etiologically  into  ileus 
caused  by  operations  on  the  mesentery,  by  prolonged  strangulation, 
by  spinal  injuries,  by  strangulation  of  the  omentum,  by  hepatic  and 
renal  colic,  by  compression  of  an  ovary,  by  local  and  general  peri- 
tonitis, by  embolism  and  thromfo-phlebitis  and  last,  but  by  no  means 
least  in  importance  and  frequency,  by  afferent  nerve  trauma. 


GYNECOLOGY.  53 

Post-operative  intestinal  obstruction  from  mechanical  and  septic 
causes  has  been  frequently  and  fully  brought  before  the  profession. 
While  the  importance  of  post-operative  ileus  from  nerve  injury  has 
not  received  the  attention  that  it  should,  one  reason  is  that  it  is  gen- 
erally confounded  with  some  other  variety,  especially  the  septic  form, 
which  is  often  added  to  the  former  in  a  few  hours  if  not  relieved.  The 
nervous  distribution  of  the  intestinal  canal  is  derived  from  the  solar 
plexus.  The  impressibility  and  sensitiveness  of  this  part  of  the  nerv- 
ous system  is  not  excelled  in  any  part  of  the  body,  and  it  is  little  to 
be  wondered  that  over-stimulation  from  injury  is  followed  by  a  paresis 
of  the  muscular  coat  of  the  intestine  to  which  the  afferent  or  motor 
nerve  is  distributed."' 

"A  bowel  that  has  been  exposed  to  the  air  for  a  long  time  until  it 
has  become  blanched  and  dry,  one  that  has  been  subjected  to  rough 
manipulation,  or  has  had  its  mesentery  or  coats  torn  or  lacerated  in 
separating  adhesions,  has  sustained  sufficient  injury  to  lose,  by  reflex 
paresis,  its  functionary  powers,  both  of  absorption  and  peristalsis. 
The  intestinal  canal  is  nature's  sewer  and  great  drainage  tube  of  the 
peritoneal  cavity  after  abdominal  section.  Arrest  its  functions,  and 
see  what  occurs.  Pathogenic  bacteria  in  the  canal  multiply  rapidly, 
digestion  is  interfered  with,  gases  form  quickly,  the  coats  of  the  intes- 
tine are  distended  and  thinned,  so  that  micro-organisms  findeasy  access 
through  the  thin  walls  into  the  peritoneal  cavity,  and  paresis  from 
septic  peritonitis  is  often  quickly  added,  and  is  rapidly  fatal.  That 
these  cases,  in  all  instances,  are  septic  from  the  beginning,  if  done 
under  aseptic  conditions,  I  do  not  believe.  How  many  of  us  have  seen 
cases  of  intestinal  obstruction  when  we  have  been  on  the  eve  of  reopen- 
ing the  abdomen,  and  in  a  half  hour  after  purgation  have  our  patients 
convalesing  and  recover  without  any  other  bad  symptom.  These  are 
cases  of  raflex  paresis  from  nerve  injury,  and  are  not  primarily  septic 
aa  usually  thought,  though,  if  not  relieved,  may  become  so  Disten- 
sion of  the  intestines  from  reflex  paresis  may  come  rapidly  or  slowly. 
I  believe  to  a  great  extent  it  depends  upon  the  preparatory  treatment 
of  the  intestinal  canal  prior  to  the  operation.  An  intestinal  canal  that 
has  been  thoroughly  emptied  by  purgation,  and  has  only  been  allowed 
animal  broths  for  thirty-six  hours  prior  to  the  operation,  and  has  been 
subjected  to  the  action  of  intestinal  antiseptics,  is  not  so  liable  or  so 
early  followed  by  distension  and  increasing  obstruction.  By  this 
careful  preparation  I  am  confident  that  time  is  given  the  nerve  and 
nerve  centres  to  regain  their  proper  function  before  distension  from 
gases  has  occurred  and  the  increased  inhibitory  action  incident  to  the 
gaseous  distension."  "In  every  instance  the  problem  to  solve  is, 
whether  we  have  to  contend  with  a  case  of  traumatic,  septic,  or  me- 
chanical ileus." 

"Rapid  operations,  the  avoidance  of  exposure  and  rough  handling 
of  the  intestines,  the  repairing  of  all  peritoneal  injuries  as  far  as  pos- 


GYNECOLOGY. 
54 

sible,  the  prevention  of  traction  on  the  intestinal  walls,  are  all  im- 
portant in  lessening-  the  danger  of  a  paretic  bowel  due  to  nerve  injury. ' ' 

"My  routine  practice  is  to  begin  on  the  second  da,y  after  operation, 
or  so  soon  as  any  untoward  symptoms  appear,  the  broken  doses  of 
calomel,  followed  by  high  enemata  of  salts,  glycerin,  turpentine  or 
peppermint.  If  this  fails,  magnesia  sulphate  by  mouth  is  adminis- 
tered and  this  is  augmented  by  the  continued  administration  of 
hi<j-h  enemata.  In  simple  cases  large  enemata  of  peppermint  water 
will  not  infrequently  secure  the  discharge  of  a  great  quantity  of 
o-as,  with  intense  relief  to  the  patient,  which  usually  culminates  in  re- 
freshing sleep.  There  is  no  single  effect  of  a  drug  in  the  whole  surgi- 
cal practice  more  strikingly  beneficent  than  a  pu.-gative  in  paretic 
ileus . ' ' 

"Should  all  efforts  fail,  and  septic  paresis  or  peritonitis  be  added, 
as  a  last  resort  we  have  to  consider  the  propriety  of  reopening  the 
abdomen,  and  washing  out  or  sponging  out  the  abdominal  cavity." 

"Much  has  been  written  on  the  treatment  of  peritonitis  by  purgatives. 
It  is  not  so  much  the  peritonitis  as  the  paretic  ileus  which  is  cui'ed  by 
purgatives.  Cure  the  paretic  ileus,  and  you  Vi^ill  prevent  the  septic 
peritonitis.  I  do  not  believe  a  case  of  septic  peritonitis  was  ever  cured 
by  purgatives  alone,  and  I  believe  that  a  paretic  ileus  from  nerve  in- 
jury alone  may  be  sufficient  to  produce  death  by  systemic  intoxication 
f-om  the  absorption  of  the  decomposed  intestinal  contents  and  the  dis- 
tension incident  to  the  paresis."  H.  S.  L. 


Post-Operative  Lesions  and  Sequels. — (Amer.  Jour,  of  Obstet- 
rics, October  1897.  Read  before  Amer.  Asso.  of  Obstetricians  and 
Gynecologists,  Niagara  Falls,  August  17  to  20, '1897).  n  Joseph  Price 
says:  "It  must  have  come  to  the  notice  of  many  of  you  that  there  are 
numbers  of  useless,  often  harmful,  operations.  It  seems  a  common 
affair  for  surgeons,  or  those  passing  as  such  to  work  some  little  end  at 
the  expense  of  all  the  risk  of  a  regular  operation.  They  have  only 
in  view  some  temporary  or  peculiar  benefit,  v/ithout  sufficient  consider- 
ation of  the  subsequent  work  necessary  to  coraplete  cure.  Our  great 
aid  lies  in  the  recuperative  abilities  of  the  patient,  and  what  can  one 
expect  when  her  vital  powers  are  taxed  for  recovery  from  numerous 
ill  judged  operations?  It  is  surely  a  matter  for  considerable  caution. 
The  excuses  are  few  for  repeated  operations.  We  will  view  repeated 
operations  from  two  standpoints;  one  is  where  pathological  conditions 
and  the  broken-down  condition  of  the  patient  ai"e  such  as  to  render  a 
complete  operation  of  extreme  peril  to  the  patient.  To  determine  this 
question,  the  extent  to  which  procedure  is  safe,  is  one  of  the  most  seri- 
ous that  appeal  to  surgical  judgment.  It  is  only  such  conditions  that 
justify  leaving  anything  for  a  second  operation.  The  other  and  more 
frequent  reason  for  re-operation,  the  one  least  to  be  justified,  the  one 


GYNECOLOGY.  rtf 

a  reproach  upon  our  surgery,  is  the  attempted  work  of  ignorance  or 
that  which  cowardice  leaves  uncompleted." 

"Statistics  have  become  too  much  a  matter  of  mere  advertising  con- 
cern and  are  therefore  of  little  value.  All  of  us  are  concerned  in  our 
mortality,  all  want  their  patients  to  recover  but  mere  recovery  from  an 
operation  does  not  in  very  many  instances  mean  a  cure;  the  terms  are 
not  synonymous.  Indeed,  the  condition  of  the  patient,  after  so-called 
recovery  from  certain  operations,  is  worse,  the  suffering  greater,  life 
in  greater  peril  than  before.  Mere  experiment  is  responsible  for  very 
many  repeated  operations.  This  experimenting  is  not  limited  to  the 
young,  those  fresh  from  our  college  benches.  Experience  convinces 
me  that  many  of  our  young  men  are  more  conscientious  than  some  of 
their  seniors.  They  push  their  special  work  until  they  have  a  fitness 
for  it.  This  they  can  aif  ord  to  do,  for  when  they  begin  they  will  know 
how  and  therein  lies  the  secret  we  are  all  seeking."  "In  every  case 
there  should  be  a  reasonable  certainty  as  to  existing  trouble,  otherwise 
it  is  impossible  to  determine  upon  the  method  of  treatment.  But  the 
error  is  not  always  of  diagnosis;  the  operator  may  be  moved  by  the 
craze  to  operate.  The  subjects  of  these  unjustifiable  operations — oper- 
ations for  slight  or  undefined  troubles — receiving  no  relief,  will  permit 
a  real  trouble  to  grow  until  conditions  become  such  that  relief  by  the 
most  skillful  surgery  is  difficult  and  of  uncei'tain  result.  In  many  of 
the  cases  of  repeated  operations,  the  primary  operation  was  unjustifi- 
able; there  was  error  of  diagnosis;  doubt  and  speculation  in  the  mind 
of  the  operator  as  to  existing  trouble.  The  primary  operation  may 
create  conditions,  set  up  adhesions,  which  make  the  second  operation 
difficult  and  dangerous.  All  forms  of  exploratory  operations  imply 
ignorance  and  doubt,  and  are  responsible,  for  much  of  the  work  which 
has  to  be  repeated.  It  is  true  that  there  are  cases  whei'e  an  explora- 
tory procedure  serves  a  good  purpose,  and,  when  done  under  proper 
surgical  method  and  with  absolute  cleanliness,  involves  no  great  risk 
to  the  patient.  It  should  be  kept  in  mind  that  all  surgical  procedures 
involve  more  or  less  risk. 

The  tolerance  of  the  peritoneum  has  tempted  to  a  great  deal  of  sur- 
gical nonsense,  often  to  a  carelessness  or  rashness  which  sets  up  patho- 
logical conditions  requiring  radical  surgery  for  their  correction.  We 
will  name  a  few  of  the  procedures  which  give  us  a  large  percentage  of 
second  operations:  1.  Dilatation  and  curettment.  2.  Vaginal  punc- 
ture. 3.  Vaginal  hysterectomy.  Then  comes  the  operation  that  cures 
— abdominal  section,  the  freeing  of  omentum  and  bowel,  both  large 
and  small,  the  removal  of  pathological  condition,  irrigation  and  drain- 
age." 

"In  appendicitis  a  second  operation  occurs  to  relieve  obstruction  or 
break  up  adhesions  which  were  the  result  of  the  incomplete  primary 
operation.  In  many  of  these  cases,  as  in  others  the  complications  are 
so   great  and  extensive  that  the  operator,  not  having  the  knowledge 


.  GYNECOLOGY. 

and  si  ill,  or  lacking  courage,  abandons  the  procedure  with  the  en- 
tirely too  common  apology  'inoperative,'  'hopeless.'  The  freeing  of 
visceral  adhesions  in  primary  operations  is  rare  and  for  this  reason 
very  much  work  is  to  be  gone  over  again  with  all  the  difficulties 
aggravated  tenfold.  Too  many  operators  are  content  with  the  simple 
removal  of  a  growth,  with  correcting  the  fixation  or  pathological  con- 
ditions about  it.  A  partially  adherent  bladder,  if  not  freed,  will  re- 
main a  perpetual  source  of  annoyance.  Bands  of  adhesion  about  the 
ileum,  if  not  freed,  form  the  post-operative  obstruction  we  see  so  com- 
monly reported.  The  removal  of  remaining  and  irritated  material, 
careful  trimming  of  all  ragged,  fringy  adhesions,  clearing  away  of  all 
debris  and  clot,  and  vvell  placed  drainage  at  the  seat  of  ozing,  will 
favor  a  perfect  cure,  It  is  sometimes  necessary  to  retie  old  pedicles 
when  portions  of  original  cyst  or  tumor  remain  in  the  pedicle,  and  cut 
or  scrape  with  a  sharp  knife  the  dirty  seat  of  dead  ligatures  and  stitch 
healthy  peritoneum  over  those  parts." 

"Unfortunately  too  many  poor  women  continue  to  suffer  from  post- 
operative lesions;  they  are  told  to  have  patience,  that  the  symptoms 
will  vanish.  Very  frequently  there  is  opposition  on  the  part  of  the 
physician  to  reopening  and  correcting  the  mischief;  some  look  upon 
visceral  adhesions  as  necessarily  fatal.  A  few  do  not  consider  an  op- 
eration complete  until  all  visceral  adhesions  have  been  carefully  freed 
and  repaired  and  left  in  as  normal  a  condition  as  possible;  after  the 
repair  of  viscera  for  the  removal  of  growths  placing  all  viscera  in 
pathological  relation.  A  number  of  operators  remove  tumors  without 
examining  surrounding  parts.  When  we  hear  of  a  case  operated  upon 
two  or  three  times  by  the  same  operator  we  have  no  difficulty  in  form- 
ing an  estimate  of  his  surgical  ability.  We  know  that  in  his  primary 
operation,  in  his  second  and  probably  third  ventui-e,  he  left  something 
behind  he  should  have  removed;  all  through  he  was  doing  incomplete 
work.  We  fully  realize  that  too  much  surgery  in  extremely  debilitated 
patients  will  kill  just  as  surely  as  none  at  all.  Methods  of  procedure 
have  much  to  do  with  the  necessity  for  repeating  operation." 

Our  courage  should  be  strong;  we  want  great  masters  in  our  science 
to  grow  up  among  us.  Frequently  some  one  of  our  medical  or  surgi- 
cal brothers  comes  running  out  of  the  bushes,  crying,  "I  have  found 
something."  It  is  usually  a  bug  and  antitoxin  or  a  new  method. 
There  are  few  more  potent  factors  in  the  mid-direction  of  our  surgical 
efforts  than  the  impoi-tunities  of  our  subjects  for  immediate  bodily 
relief  or  comfort.  This  idea  has,  I  am  sure,  more  influence  with  the 
younger  practitioners  anxious  to  please  and  show  their  resources. 
This  brings  up  the  important  fact  that  a  clear  judgment  as  to  methods 
for  the  eventual  welfare  of  the  patient  must  be  uninfluenced  by  any 
consideration  of  present  desire.  Of  course  we  would  not  bar  any  harm- 
less comfort,  since  we  aim  always  at  a  favorable  condition  of  mind; 
but  there  can  be  no  doubt  that  even  a  quick  sympathy  will  urge  the 


CORRESPONDENCE  .  cy 

physician  to  hesitancy  or  a  I'ash  performance.     He  must  be  far  above 
any  effects  of  the  patient's  talk." 

'  'As  we  age,  as  our  experiences  crowd  upon  us  our  science,  with  all 
its  mysteries,  becomes  a  clearer  science;  and  the  more  weighty  grow 
our  responsibilities,  the  more  enlarged  our  conceptions  of  duty,  we 
feel  the  more  keenly  the  issues  we  carry  in  our  hands — there  is  sensi- 
tiveness to  all  breathing  about  us. "  H.  S.  L. 


Correepon^ence. 


AN  APPEAL 

TO    EVERY   REGISTERED    PHYSICIAN    AND    LICENSED    MIDWIFE  IN   THE 
UNITED  STATES,  FOR  INFORMATION   CONCERNING  CRIIVUNAL  ABOR- 
TION. 


Dear  Doctor: — I  most  earnestly  appeal  professionally  to 
each  of  you,  regardless  of  your  school  of  practice,  your  prom- 
inence in  the  medical  profession,  or  your  location,  to  answer  the 
questions  given  below  In  replying  please  designate  each  ques- 
tion by  its  number.  Answers  can  be  made  in  numerals,  and  if 
you  do  not  elect  to  respond  by  letter  a  postal  card  will  do  as 
well.  The  face  of  such  a  card  will  present  only  an  aggregation 
of  meaningless  figures  to  all  who  handle  it  except  ourselves. 

However,  I  will  highly  appreciate  whatever  you  may  impart 
in  relation  to  criminal  abortion  otherwise  than  may  be  con- 
tained in  your  answers  to  my  questions.  I  trust  your  visiting 
list,  your  cash  and  account  books,  and  other  data  in  your  pos- 
session, will  enable  you  to  give  definite  or  approximate  answers 
without  consuming  too  much  of  your  time.  If  the  115,000  to 
120,000  physicians  in  the  United  States  will  kindly  give  the  in- 
formation I  ask,  I  will  return  to  them  through  the  medical 
press,  some  time  during  1898,  a  summary  of  the  results  of  my 
investigation. 

I  desire  to  assure  you  that  every  line  given  me  on  the  subject 
of  my  inquiries  will  be  held  strictly  private,  if  you  requst  it, 
and  should  you  not  request  its  privacy,  I  will  give  it  good  treat- 
ment. If  for  any  reason  you  wish  to  withhold  your  full  name 
your  initials  will  suffice.     Remember  my  inquiries  cover  the 


Q  CORRESPONDENCE. 

year  1897,  and  where  you  cannot  give  a   definite  answer  an  ap- 
proximate answer  is  desirable: 

QUESTIONS. 

1.  Give  total  number  of  abortions  from  all  causes  that  oc- 
curred in  your  practice  during  1897?* 

2.  In  how  many  of  these  abortions  were  the  elements  of  crim- 
inality, to  your  mind,  apparent? 

3.  In  how  many  of  these  abortions,  except  those  classed  in 
question  2,  were  the  elements  of  criminality,  to  your  mind, 
probable? 

4.  How  many  of  the  abortions  named  in  questions  2  and  3 
were  followed  by  puerperal  septicaemia  or  other  diseases? 

5.  How  many  deaths  resulted  from  the  abortions  named  in 
questions  2  and  3? 

6.  How  many  still-born  in  your  practice. 

7.  How  many  infanticides? 

8.  How  many  viable  children  born  in  your  practice? 

9.  How  many  cases  of  puerperal  mania  resulted  from  the 
abortions  classed  in  questions  2  and  3? 

All  midwives  who  are  licensed  are  solicited  and  urged  to 
answer  the  above  questions  so  far  as  their  knowledge  enables 
them.  Doctor,  permit  me  again  to  beg  that  you  answer  my  in- 
quiries either  definitely  or  approximately^  and  if  for  any  reason 
you  cannot  fully  answer  all  do  your  best  on  questions  two, 
three,  five  and  nine.  Medical  journals  throughout  the  United 
States  are  requested  to  favor  the  undersigned  with  an  insertion 
of  these  questions  in  their  January  or  February,  1898,  issues. 
C.   D.   ARNOLD,  M.D.,  El  Reno,  Okla. 

*NoTE — Question  i  should  include  abortion  which  you  know  occurred 
among  your  lady  patrons  without  the  attention  of  a  reputable  physician. 
Any  abortion  'vhat  resulted  from  an  obstinate  disregard  on  the  part  of  the 
woman,  of  a  physician's  advice,  or  from  the  wilful  commission  of  any  act 
which  her  observation,  experience  and  other  knowledge  gave  her  reason  to 
believe  might  induce  immediately  or  even  remotely  the  expulsion  of  the 
uterine  contents,  was  criminal.  (Any  act,  however  simple,  occurring  in  the 
daily  avocation  of  a  pregnant  woman,  if  impelled  by  an  intent,  or  even  a 
desire  or  wish  to  get  rid  of  her  pregnancy,  is  criminal  whether  she  aborts  or 
not.)  I  use  the  word  "abortion"  here  to  mean  the  expulsion  of  the  products 
of  conception  at  any  time  during  gestation  to  the  end  of  the  seventh  month, 
if  the  abortion  was  unavoidable,  and  to  full  term,  if  criminal. 


^berapeutlc  Ibtnts, 


Benzoate  of  Soda  in  the  Treatment  of  Grippe. — Accord- 
ing to  the  News  no  drug  has  given  more  favorable  results  in 
the  treatment  oi  grippe  than  benzoate  of  soda.  It  may  be  given 
in  capsule  or  powder  form,  the  usual  dose  being  lo  grn.,  three 
or  four  times  a  day.  When  muscular  symptoms  are  pronou  need, 
the  following  combination  acts  admirably: 

Sodii  benzoas 2  dr. 

Salol I  dr. 

Phenacetin l^  Z"^- 

M.,  and  ft.    chart  No.    xii.      Sig.— One  powder  every  four 
hours. — Gaillards  Med.  Jou7\ 

Prof.  Neumann's  Cautions. — In  an  article  upon  "Exces- 
sive Treatment  in  Disorders  of  Infants,"  the  specialist  in  pedi- 
atrics, Neumann,  of  Berlin,  gives  the  following  warnings: 

1.  Do  not  bathe  the  infant  and  thus  remove  the  vernix  caseosa, 
which  is,  itself,  aseptic.  The  first  bath  should  be  given  after 
the  navel  wound  has  healed. 

2.  Avoid  too  much  cleansing  of  the  mouth  of  che  infant  by 
rubbing  and  scrubbing  it  out. 

3.  Refrain  from  scarifying  the  gums  with  the  idea  that  denti- 
tion is  a  pathologic  process. — Med.    Council. 


nDiscellaneoue  Items. 


The  Committee  of  Arrangements  have  decided  upon  May 
3d,  4th  and  5th  as  the  date  for  the  meeting  of  the  State  Medi- 
cal Society  in  Charlotte. 

"Cuba  is  the  natural  breeding  ground  for  yellow  fever,  and 
will  continue  to  be  as  long  as  it  remains  under  Spanish  rule; 
the  Spanish  authorities  are  criminally  indifferent  and  neg- 
ligent to  the  spread  of  fever;  and  the  island  in  its  present 
condition  is  a  dangerous  menace  to  the  public  health  of  the 
United  States." — Dr.  John  Guiteras. 


6o 


MISCELLANEOUS  ITEMS. 


We  would  consider  it  a  special  favor,  doctor,  if  when  writing 
to  any  of  our  advertisers  you  would  always  mention  the  N,  C. 
Med.  Jour. 

We  are  pleased  to  note  that  Dr.  J.  D.  Roberts,  who  removed 
to  Florida  a  few  years  since,  has  recently  located  in  Kerrers- 
ville,  N.  C,  We  heartily  welcome  the  doctor  back  to  the  Old 
North  State. 

The  friends  of  Dr.  A.  R,  Wilson,  Greensboro,  N.  C,  will 
regret  to  learn  of  his  sad  bereavement  in  the  death  of  his  little 
son,  aged  7  years.  The  little  fellow  died  from  the  effects  of 
burns  received  by  the  ignition  of  his  clothing  while  he  was 
standing  before  an  open  fire,  preparatory  to  retiring. 

The  University  of  California  and  Hahnemann  College. — 
At  the  last  meeting  of  the  Regents  of  the  University  of  Cali- 
fornia, the  petition  of  the  Hahnemann  Hospital  College  re- 
questing admission  to  the  University  was  rejected.  Fourteen 
members  voted  against  and  four  in  favor  of  the  affiliation. — Ex. 

Responsibility  of  Water  Companies. — A  jury  at  Steven's 
Point,  Wis.,  recently  returned  a  verdict  in  favor  of  the  plain- 
tiff in  the  sum  of  $5,000  damages  against  the  Ashland  Water 
Company.  The  cause  of  action  was  the  alleged  negligence  of 
the  water  company  in  furnishing  impure  and  unwholesome 
water,  containing  typhoid  germs,  to  the  plaintiff's  husband, 
thereby  causing  his  death. — Medical  News. 

We  return  our  thanks  to  the  Antikamnia  Chemical  Co.,  of 
St.  Louis,  for  extra  copies  of  their  unique  calendar  for  1898. 
They  announce  that  they  have  sent  a  copy  to  every  English 
speaking  physician  in  the  world,  whose  address  they  have  from 
a  reliable  source.  They  inform  us  that  any  of  our  readers  who 
have  been  overlooked  will  receive  a  copy  if  they  will  make  ap- 
plication to  the  company  and  will  enclose  their  printed  profes- 
sional card  or  prescription  blank. 

General  Brailmont,  basing  his  estimate  upon  the  law  of  Mal- 
thus  that  when  the  population  is  not  arrested  by  any  obstacle 


mSCELLANEOUS  ITEMS.  6 1 

It  doubles  every  twenty-five  years,  calculates  that  the  popula- 
tion of  the  world  in  the  year  2282  will  be  30,000,000,000  and  he 
estimates  that  at  that  future  date  only  about  4,900,000,000 
acres  of  land  will  be  available  for  raising  food,  and  that  this 
acreage  will  be  sufficient  to  nourish  only  6,000,000,000  persons 
the  year  around,  and  since  under  his  calculations  the  popula- 
tion of  the  world  will  surely  stand  at  that  figure  in  about  176 
years  he  further  concludes  that  in  about  400  years  from  now 
the  population  of  the  world  will  be  so  vast  that  the  inhabitants 
cannot  possibly  be  fed  and  many  must  of  necessity  die  annually 
of  starvation. — Jour.  Med.  and  Science. 

Rush  Medical  College  has  been  successful  in  its  effort  to  be- 
come affiliated  with  the  University  of  Chicago.  The  date  de- 
cided upon  for  the  consummation  of  the  relationship  is  June  i, 
1898. 

A  Progressive  Potentate. — The  young  Emperor  of  China, 
with  a  lost  faith  in  the  traditional  remedies  of  his  people,  has 
dispatched  to  the  medical  centres  of  Europe  a  large  number  of 
students.  London,  Paris,  Berlin  and  Vienna  have  already  re- 
ceived a  respectable  instalment. — Maritime  Med.  Neivs. 

The  Lefoten  Islands  and  Their  Principal  Products  is  an  inter- 
esting little  brochure  published  by  Parke,  Davis  &  Co.  It 
gives  an  illustrated  description  of  the  cod  fisheries  of  that  sec- 
tion, and  the  preparation  of  the  fish  and  the  oil  for  market. 
The  very  appropriate  frontispiece  is  a  full-sized  reproduction  of 
a  bottle  of  their  Egg  Emulsion  of  Cod  Liver  Oil. 

The  Physicians  in  the  counties  of  Virginia  and  North  Caro- 
lina neighboring  to  Norfolk,  Va.,  are  to  organize  a  "Tidewater 
Medical  Association"  the  meeting  for  organization  being  called 
for  January  20th,  in  Norfolk.  The  announcement  is  signed  by 
thirty-three  physicians.  It  is  stated  that  "it  is  not  intended 
that  this  Association  shall  in  any  way  conflict  with  the  State 
Medical  Association  of  either  Virginia  or  North  Carolina,  but 
the  purpose  in  calling  this  meeting  is  to  bring  together  the  phy- 
sicians of  our  section,  so  that  we  may  become  better  acquainted 
and  for  the  benefits  to  be  derived  from  the  discussion  of  papers, 


5^  MISCELLANEOUS   ITEMS. 

reports  of  cases,  clinics,  etc."  The  meeting  will  be  held  in  the 
rooms  of  the  Young  Men's  Christian  Association,  and  an  ad- 
dress of  welcome  will  be  made  by  the  Mayor  of  Norfolk.  We 
acknowledge  the  courtesy  of  an  invitation  to  attend  the  meet- 
ing, and  extend  to  the  new  Association  our  congratulatioas  and 
best  wishes. 

Koch's  Renderpest  Remedy. — The  Government  of  the  Cape 
of  Good  Hope  is  now  regretting  the  money  spent  in  securing 
Kock  to  elaborate  a  protective  serum  for  use  against  the  rinder- 
pest. The  undertaking  has  ended  in  absolute  failure,  for  the 
inoculation  has  had  no  effect  in  preventing  the  cattle  from  dying 
of  the  disease.  It  is  said  that  Koch  is  about  to  return  to  South 
Africa  to  renew  his  experiments  and  try  once  more  to  make  an 
effective  serum.  The  Medical  Press  and  Circular  says  that  the 
Cape  Government  "has  not  found  that  its  introduction  of  a 
German  professor  into  the  colony  has  had  any  other  effect  than 
that  of  costing  it  a  large  sum  of  monciy.  Perhaps  upon  the 
next  occasion  that  some  official  bacteriological  investigations 
are  required  it  will  bear  in  mind  that  science  made  in  Germany 
is  no  better  than  science  made  elsewhere;" — and  our  contem- 
porary might  have  added,  it  has  of  late  acquired  a  decidedly 
commercial  character. — Med.  Age. 

A  Case  of  Small-Pox  in  Wilmington,  N.  C. — On  the  12th 
of  January  a  well-defined  case  of  small-pox  was  reported  in  one 
of  the  negro  districts  of  this  city  and  immediately  taken  charge 
of  by  the  city  health  authorities.  The  house  and  all  the  in- 
mates were  placed  under  strict  quarantine  and  preparations 
made  for  the  removal  of  the  patient  to  an  old  building  on  the 
outskirts  of  the  city,  which  was  to  have  been  converted  into  a 
pest  house.  This  was  a  very  unwise  move  on  the  part  of  the 
health  authorities  and  it  immediately  met  with  the  resistance  of 
an  organized  and  armed  mob.  The  authorities  then  turned  to 
the  other  extremity  of  the  city  where  they  were  met  by  an  even 
more  determined  mob,  which  went  so  far  as  to  destroy  by  fire 
the  buildings  which  had  been  selected.  The  consequence  is 
that  the  patient  remains  in  the  house  in  which  he  was  discov- 
ered, which  we  consider  the  best  place  for  him,  unless  he  were 


READING  NOTICES.  Q^ 

removed  out  of  the  city.  At  the  time  we  write  one  other  sus- 
picious case  is  under  observation.  The  present  conditions  show 
how  unyvise  it  is  to  wait  for  the  appearance  of  small-pox  in  a 
community  before  vaccination  is  practiced.  It  is  impossible  to 
secure  at  once  vaccine  points  in  sufficient  quantity  to  meet  the 
sudden  demand.  While  we  believe  that  the  outbreak  will 
amount  to  little  more  than  a  scare,  we  trust  that  the  scare  will 
continue  until  every  unprotected  person  in  the  city  has  been 
vaccinated. 


NECROLOGY. 


Dr.  Cornelius  N.  Dorsat,  aged  44  years,  December  nth,  at 
Montgomery,  Alabama. 

Dr.  A.  W.  Peurifoy,  aged  69  years,  December  10th,  at  Hank- 
insville,  Georgia. 

Col.  James  Cooper  McKee,  a  retired  army  surgeon,  aged  67 
years,  dropped  dead  December  nth,  at  Butler,  Pa. 


"KeaMno  1Botices» 


"Robinson's  Lime  Juice  and  Pepsin"  is  an  excellent  remedy 
in  the  gastric  derangements  particularly  prevalent  at  this  season. 
It  is  superior  as  a  digestive  agent  to  many  other  similar  goods. 
(See  page  2,  this  issue).  See  remarks  on  their  Arom.  Fluid 
Pepsin  also. 

Pthisis;  Winter  Cough. — The  treatment  of  Pthisis,  or  Pul- 
monary Tuberculosis,  is  ever  of  interest  to  the  practitioner  of 
medicme;  at  this  time  of  the  year,  especially  so.  Like  the 
poor,  "it  is  always  with  us."  So  many  specifics  for  this  affec- 
tion have  from  time  to  time  been  heralded  to  both  the  profes- 
sion and  the  public,  that  it  is  doubtless  true  that  thousands  of 
human  lives  have  been  sacrificed  while  demonstrating  worth- 
lessness  (their).  It  has  time  and  again  been  proved  that  the 
best  results  in  this  disease  can  be  attained  by  the  use  of  what 
I  may  term  "standard"  remedies,  and  not  in  the  waste    of  time 


.  READING  NOTICES. 

64 

in  experimenting   with  seeums,    and   other   impositions  on   the 
medical  fraternity. 

Prominent  among  the  standard  remedies  referred  to,  stands 
one  that  may  with  be  called  "Nature's  Own  Remedy,"  in  as 
much  as  it  is  obtained  from  the  very  bowels  of  Mother  Earth — 
Petroleum. 

The  Angier  Chemical  Co.,  of  Boston  have  placed  this  remedy 
in  our  path  in  palatable  form,  combining  with  it  the  well  known 
Hypophosphites.  This  Emulsion  supersedes  cod-liver  oil  in 
more  ways  that  one,  not  the  least  of  which  is  that  it  is  palata- 
ble; consequently,  does  not  disorder  digestion  or  produce 
nausea.  This  in  many  cases  is  of  the  greatest  importance.  In 
regard  to  its  therapeutics  it  may  be  said  that  it  is  antiseptic, 
antispasmodic,  stimulant,  nutrient  and  expectorant.  By  its  use 
the  cough  is  at  once  ameliorted,  the  perspiration  is  diminished, 
the  patient  is  strengthened,  thereby  enabling  him  to  expectorate 
the  loosened  mucus  with  greater  ease;  fetid  odors  are  made 
less  so,  and  frequently  the  consumptive  steadily  improves  and 
regains  health.  In  the  first  stages  of  this  disease  it  is  certainly 
curative,  as  can  be  verified  by  any  practitioner  giving  it  a  faith- 
ful trial. 

In  the  commoner  coughs,  often  spoken  of  as  winter  coughs, 
even  when  not  of  tubercular  origin — and  also  in  Bronchitis, 
Angler's  Petroleum  Emulsion  is  invaluable.  Here  it  exerts  the 
the  same  action  on  the  cough,  expectoration  and  mal-nutrition, 
as  in  the  former  conditions  and  other  medication  is  rarely  re- 
quired. In  the  vague  and  ill  defined  chest  pains  of  those  re- 
covering from  an  attack  of  pneumonia,  pleurisy  or  grippe,  this 
preparation  is  specially  indicated.  The  improvement  in  diges- 
tion which  always  follows  its  use  is  one  of  its  promineut  feat- 
ures, and  It  is  therefore  also  adapted  to  all  forms  of  m.al-nutri- 
tion  in  old  or  young. 

It  is  not  my  purpose  in  this  paper  to  quote  particular  cases 
treated,  bMt  simply  to  direct  attention  to  Angler's  Petroleum 
Emulsion  of  those  who  may  not  have  learned  of  it  and  especi- 
ally to  those  physicians  who  are  prescribing  Cod-Liver  Oil,  but 
wha  desire  something  more  efficacious  and  more  acceptable  to 
the  patient's  palate  and  stomach.  J.  D.  ALBRIGHT,  M.D. 
Pottsville,  Pa. 


DOCTOR: — Your  library  is  not  complete  without  the  Hyp- 
notic Magazine.  Cost  of  this  handsome  monthly,  including 
premium  book  on  Suggestive  Therapeutics  is  only  one  dollar 
($1.00)  a  year. 

THE  PSYCHIC  PUBLISHING  CO., 

56  5th  Avenue,    Chicago. 


ALWAYS   THE  SAME. 
A  STANDARD  OF  ANTISEPTIC  WORTH 


LiSTERINE. 


» 


LISTERINE  is  to  make  and  maintain  surgical  cleanliness  in  the  anti- 
septic and  prophylactic  treatment  and  care  of  all  parts  of  the  human 
body. 

LISTERINE  is  of  accurately  determined  and  uniform  antiseptic  power, 
and  of  positive  originality. 

LISTERINE  is  kept  in  stock  by  all  worthy  pharmacists  CTerywkere. 

LISTERINE  is  taken  as  the  standard  of  antiseptic  preparations:  The 
imitators  all  say,    "It  is  something  like  Listerine." 


LiTHiATED  Hydrangea. 


A  valuable  Rtnal  Alttratite  and  Anii-Litkic 
agent  of  marked  servke  m  the  treatment  of 
Cystitis,  G<mt,  Rheumatism,  and  diseases  of  the 
Uric  Diathesis  gen^ralfy. 


DESCRIPTIVE  LITERATURE 

UPON  APPLICATION. 

LAPflBERT  PHARMACAL  CO.,  St.  Louis, 


l^nnOne  teaspoonful  of  Celerina 


four  times  a  day    for   voccl,    mental 


and  physical  fatigue. 


One     teaspoonful     of     Celekina 


taken  just  before  singing  or  speaking 


strengthens    the    voice. 


A   sample   bottle   will   be  sent  free  to  any  physician  who  desire- 
test  it,  if  he  will  pay  the  express  charges. 

mo  CHEMICAL  CO.,  St.  Louis,  Mo.,  U.  S.  A. 


FEVER-KILLER--AIM  ANODYNE— AN  ANTIPYRETIC 
>  "PYROCTI  N."     Doctor  have  you  tried  it?    If  not,  send  your  address 

a  Postal  card  to  Murray  Drug  Co.,  Gen'l  Ag'ts,  Columbia,  S.  C,  they  wUl 
idly  send  samples.     Sec  their  Ad'  in  this  Journal. 


rectr-Flrst   Year. 


FEBRUARY  5,  i8(^. 


rol.  41.    NO. 


NORTH  CAROLINA 

MEDICAL  JOURNAL. 

^-  PUBLISHED  SEMI-MONTHLY  AT  $2.00  PER  ANNUM. 

1?ol?ert  B.  3cwctt,  m,H).,  igbitor. 

[Entered  at  the  Post-Office  at  Wilmington.  N.  C,  as  Second-class  mail  mattcr.j 


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hKtsmSSSS 

nmmmnnnufis 


BELLEVUE  HOSPITAL  MEDICAL  COLLEGE 

CITY  OF  NEW  YORK. 
SESSI03S3"'S    OW    18Q8~Q9. 

Thb  Kmdlar  8b89io«  bciine  on  Monday,  October  8,  l!^8,  and  continues  for  ttliirty-two  weeks.    For  first's 
and  seccnd-yeai-  students,  atteiidai»o»  on  foiw  courses  of  lecture*  is  required  for  Kraduation.    Third-year 
dents  are  admitted  under  the  three-year's  system. 

Graduate*  of  other  accredited  Medloal  Colleges  are  admitted  as  third-year  studentt.    Students  who  have 
tended  one  full  regular  course  of  lectures  at  another  accredited  Medical  College  are  admitted  as  second-y^ 
students  without  medical  examination.    Students  axe  admitted  to  advanced  standing  for  the  second  or 
years,  either  on  approved  credentials  from  other  accredited  Medical  Colleges  or  after  examination  on  the 
jeots  embraced  in  the  curriculum  of  this  College. 

The  annual  circular  for  1898-9,  giving  full  details  of  the  curriculum  for  the  four  years,  the  Regents'  requiri^ 
ments  for  matriculation,  requirements  for  graduation  and  oth.^r  iu'orraatlon.  will  be  published  in  June,  1898. 
Address  Aostim  Flint,  Secretary,  Bellevue  Hos^t*!  Mwlicai  College,  26th  Street,  and  Firet  Avenue,  N«w  York 
City. 

POST  GRADUATE  INSTRUCTIOI 

Presbyterian  Eye,  Ear  aiid  Tliroat  Cliarity  Hospital  Baltimore,  Md. 

Special  instruction  will  be  given  Graduates  in  Medicine  in  External  Eye 
eases,  Refraction  (including  fitting  of  glasses),  Ear  Diseases,  and  Tliroat  and  N< 
Qiseases. 

For  further  particulars,  terms,  etc.,  address 


NORTH  CAROLINA 

MEDICAL  JOURNAL. 

A  SEMI-MONTHLY  JOURNAL  OF  MEDiCiNE  AND 
SURGERY. 

Vol.  XLI.  Wilmington,    February  5,    1898.  No.   3. 


©riginal  Communicatlong. 


QUININE    IN    MALARIA,    EXCLUDING     THE    SIMPLE 
INTERMITTENTS.* 

''Wo  viel  Licht  ist,  ist  starker  Sc/iatten.''  Goethe. — (Where    there 
is  most  light,  the  shadow  is  strongest.) 

By  J.  G.  Van  Marter,  Jr.,  M.D.,  Savannah,  Ga. 


THERE  is  a  vast  difference  between  the  action  of  Quinine  in 
the  intermittent  malarial  fevers  and  its  action   in  the  con- 
tinued malarial  fevers,  "the  Malariasubcontinuatyphoidea" 
of  the  Roman  school,  the  malarial  cachexia  and  the   debatable 
"terra   incognita"   of  Malarial   toxaemias  seen    in    hot  paludial 
countries. 

This  paper  should  properly  have  been  preceded  by  papers 
and  discussions  on  the  etiology,  pathology  and  clinical  varieties 
of  the  malarial  toxaemias  as  seen  by  us  in  this  climate.  This 
would  have  enabled  me  to  classify  the  action  of  quinine  accord- 
ing to  the  pathology  and  clinical  picture  of  each  case.  Such  a 
discussion  as  this  is  an  eminently  fitting  and  proper  one  in  our 
locality,  and  it  is  high  time  that  a  protest  be  issued  against  the 
general  acceptance  of  the  views  ef  Osier,  Thayer  and  other 
Northern  clinicians  on  the  specificity  of  quinine. 

Before  entering  into  an  argument  upon  the  specific  action  of 
quinine,  I  wish  to   state  while   Thayer  in    his  recent  work   on 
*Read  before  the  Clinical  Society  of  St.  James  Dispensary. 


gg  VAN  MARTER. -QUININE  IN  MALARIA. 

malaria  distinguishes  three  types  of  the  malarial  parasites,  the 
tertain,  the  quartan  and  the  parasite  of  £estivo  autumnal  fever, 
I  believe  that  it  is  safe  to  assert  that  there  is  more  than  one 
variety  of  parasite  in  aestivo  autumnal  malaria,  and  that  these 
parasites  have  an  entirely  different  action  as  regards  the  man- 
ufacture of  toxines. 

Under  quinine  the  forms  of  the  ordinary  cycle  of  develop- 
ment disappear  rapidly  from  the  peripheral  circulation,  bat  the 
crescentic  and  ovoid  bodies  remain  a  much  longer  time,  some- 
times even  for  months. 

In  this  paper  I  shall  abstain  entirely  from  a  discussion  of  the 
treatment  of  malaria,  either  preventive  or  curative,  but  shall 
confine  myself  as  closely  as  possible  to  the  action  of  quinine, 
and  we  shall  see  whether  quinine  is  a  true  specific  or  preven- 
tive of  the  various  forms  of  malaria  with  which  I  have  been 
acquainted,  both  here  and  in  Rome  (Italy). 

Osier,  Thayer,  Councilman  and  others  in  the  North,  speak 
truthfully  when  they  say  that  quinine  is  a  true  specific  against 
the  malarial  parasite  and  the  malarias  which  have  come  under 
their  observation,  but  as  these  gentlemen  have  not  studied  mala- 
ria in  its  true  home,  in  a  climate  fitted  for  the  development  of  the 
most  virulent  parasites,  with  infections  occurring  the  year 
around,  they  are  not  fitted,  by  either  experience  or  observation, 
to  settle  the  question  as  regards  the  action  of  quinine  in  the 
malaria  that  we  see  here.  This  applies  to  the  entire  region 
South  oi"   Charlesiion,  and  the  Gulf  Coast. 

In  the  first  place  let  us  see  whether  quinine  is  the  best  pre- 
ventive of  infection.  It  is  so  stated  by  Northern  writers,  Eng- 
lish, French  and  German  authorities,  but  is  this  the  case  v^ith 
those  who  Hue  in  tlie  egions  infested  by  the  severer  varieties  of 
malaria?  No,  they  find  by  experience  tha'  quinine  cannot  be 
iakcfi.  indefinitely  the  year  around  m  doses  sufficient  to  kill  the  par- 
asite as  fast  as  it  develops,  and  various  peoples  have  adopted 
different  measures  to  prevent  infection,  which  ^provQ  better  for 
lo7ig  continued  use. 

In  some  parts  of  Italy  they  find  that  a  strong  decoction  of 
iresh  lemons  will  prevent  infection,  while  in  otf'cr  regions  of 
Italy  the  continual  use  of  small  doses  of  arsenious  acid  acts 
well,    while   in   India,    Assam    and    Cochin-China,    the  natives 


VAN  MARTER.-QUININE  IN  MALARIA.  6? 

working  in  the  rice  fields  and  subject  constantly  to  severe  in- 
fection, find  that  opium  will  prevent  malaria  where  quinine 
fails.  This  to  me  is  very  suggestive,  being  far  better  evidence 
upon  which  to  base  conclusions  than  the  mere  hypotheses  of 
Northern  observers,  or  the  passing  observations  of  travelers, 
who,  of  course,  can  take  quinine  for  a  few  weeks  or  months. 

Now,  coming  to  the  treatment  of  malaria  (and,  of  course, 
am  always  speaking  of  the  severe  infections  and  leaving  out  of 
the  question  the  intermittent  fevers),  is  quinine  a  true  specific? 
No,  there  are  cases  innumerable  in  which  the  patient  would  die 
did  we  not  add  other  potent  drugs  to  our  quinine,  or  for  a  time 
at  least  attach  more  reliance  to  other  drugs  than  quinine,  and 
we  are  inevitably  lead  to  the  conclusion  that  although  a  true 
specific  against  the  plasmodium  of  tertian  and  quartan  fever,  it 
is  not  a  specific  or  antidote  to  the  parasite  of  the  more  severe 
continued  malarias  and  the  toxins  generated  by  them.  With 
patients  in  whom  the  microscope  has  shown  the  disease  to  be 
malaria  in  any  of  its  forms,  quinine  is  a  specific  in  all  those 
with  intermissions  or  with  marked  remissions;  not  so,  however, 
where  the  fever  is  continued,  or  in  those  malaric.s  with  but  little 
temperature. 

In  the  continued  fevers  toward  the  last  stages,  marked  remis- 
sions are  apt  to  occur  (in  the  milder  cases),  here  again  quinine 
becomes  a  specific.  There  are,  however,  exceptions  even  to 
this  rule,  for  it  is  no  uncommon  thing  to  see  a  patient  with 
intermittent  fever  to  whom  quinine  has  been  properly  adminis- 
tered, have  a  distinct  malarial  paroxysm  with  the  ears  ringing 
from  quinine. 

Dr.  Plehn,  a  German  physician  practising  in  the  Cameroons 
on  the  west  coast  of  Africa,  and  in  what  is  probably  the  most 
malarious  region  on  this  earth,  has  observed  that  quinine  is  a 
good  preventive,  and  the  best  for  treatment  in  newcomers  and 
those  not  long  resident  in  that  region,  but  in  spite  of  5  grains 
per  diem,  practically  all  foreigners  get  the  fever,  and  the  large 
majority  die  of  it  sooner  or  later.  In  all  these  cases,  with  the 
exception  which  I  shall  hereafter  note  (the  hssmaturias)  quinine 
is  given  in  enormous  doses,  with  calomel  (which,  by  the  way,  is 
never  omitted)  and  stimulants,  but  while  the  actual  paroxysm 
is  overcome  by  the  quinine  (if  the  case  be  seen    in   time,  or  not 


gg  VAN  MARTER.-QUININE  IN  MALAEIA. 

too  malignant),  the  spleen  remains  large,  the  crescents  remain  in 
the  Mood,  and  malarial  anaemia  sets  in. 

What  does  this  interesting  observation  show? 

ist.  That  quinine  is  a  specific  against  the  protozoon  of  tertian 
or  quartan  malaria. 

2d.  That  it  inhibits,  for  a  time,  the  development  of  the  pi'O- 
tozoon  of  pernicious  malaria,  but  does  not  kill  it;  nor  in  time, 
even  with  quinine  constantly  taken,  prevent  its  development, 
every  time  the  patient  catches  cold^  or  is  exposed  to  a  particularly- 
severe  contagion. 

2t^.  That  quinine  alone  has  no  action  on  the  toxine  produced 
by  grave  malarias  over  which  calomel  has  twice  the  potency  (at 
least  in  full  physiological  doses). 

4th.  That  quinine  even  as  a  prophylactic  cannot  be  indefin- 
itely taken. 

5th.  That  quinine  has  no  effect  whatsoever  on  malarial  anae- 
mia (really  a  chronic  toxaemia). 

Another  verv  interesting  form  of  protozoal  "malaria, "  beri- 
beri, is  not  cureii  by  quinine,  although  slightly  benefited  for  a 
time,  if  the  febrile  manifestations  are  sharp.  In  this  malignant 
form  of  disease,  the  pigment  bodies  seen  in  our  own  malarias 
are  deposited  in  the  brain  and  other  nerve  tissues,  and  these 
pigmented  bodies  either  before  or  after  degeneration  produce 
a  toxine  absolutely  unaffected  by  quinine.  In  the  recent  epi- 
demic at  the  Insane  Hospital,  Tuscaloosa,  Ala.,  reported  by 
Dr.  Bondurant  in  the  New  York  Medical  Journal,  it  is  stated 
that  quinine  failed  in  every  case  to  do  any  good.  It  is  to  be 
regretted  that  special  work  on  the  etiology  was  not  done,  and 
establish  the  fact  of  direct  relationship  of  the  sporoons  sup- 
posed to  cause  beri-beri. 

Still  another  variety  (more  correctly  complication)  of  malaria, 
hcemoglobinuria,  is  made  worse  by  quinine.  I  believe  that  the 
great  majority  of  those  practicing  in  countries  where  severe 
malarias  exist  will  confirm  the  observation  that  quinine  makes 
it  worse.  Thayer  admits  that  quinine  never  shortens  an  attack 
of  hemoglobinuria,  but  says  it  prevents  a  recurrence — -this 
latter  being  an  assertion  without  any  warrant  of  experience, 
and  I  know  it  to  be  wrong.     Quinine  is  a.  frequent C3i\ist  oi  haem- 


VAN  :>IA11TER.— QUININE  IN  MALARIA.  gp 

oglobinuria,  and  after  one  attack,  if  quinine  be  taken,  is  very 
apt  to  cause  the  condition  ivhich  Thayer  says  it  will  prevent. 

In  my  experience  the  cases  of  malaria  (as  proven  by  the  micro- 
scope), in  which  quinine  failed  to  cure — hence  did  not  act  as  a 
specific — iiave  been  confined  to  two  types,  ist,  and  most  com- 
mon, severe  malaria  subcontinua  typhoidea  (an  aestivo-autum- 
nal  form)  where  the  fever  ran  along  tor  days  with  very  slight 
remissions;  and  2d,  those  irregular  forms,  sometimes  seen, 
where,  with  undoubted  malaria,  the  fever  of  a  continued  type 
is  low,  seldom  above  102,  the  symptoms  presented  are  those  of 
a  profound  toxaemia  resembling  uraemia,  suppression  of  urine, 
jaundice,  delirium,  subsultus,  without  chills  or  paroxisms  of 
any  kind. 

I  will  observe  here  that  there  are  cases  of  both  types,  above 
mentioned,  that  would  surely  die,  did  we  not  add  other  drugs 
to  our  quinine,  and  that  a  large  proportion  of  cases  for  a  time 
at  least  are  better  off  without  it.  We  must  recognize  that  in 
these  types  we  hove  a  toxaemia  which  I  claim  is  unaffected  by 
quinine. 

Ir  treating  these  very  severe  malarial  toxaemias  as  wc  see  them 
in  the  country  or  plantations  just  out  of  town,  or  if  nearer, 
only  in  the  suburbs,  or  in  river  sailors,  we  are  placed  at  a  great 
disadvantage  as  regards  doing  the  best  possible  for  oar  patients. 
Perhaps  in  these  very  cases  if  our  patients  could  be  moved 
av/ay  from  an  atmosphere  whence  constant  reinfection  is  taking 
place,  and  taken  to  a  grand  hospital  like  the  Johns  Hopkins  in 
Baltimore,  where  the  poor,  even,  can  obtain  luxuries,  and  under 
skilled  trained  nursing,  perhaps  in  such  cases  quinine  might  help 
our  patient  if  proper  eliminative  treatment  were  added  (for  it 
would  not  without  it) ;  but  how  is  it  with  us,  the  patient  in  a 
miserable  hut,  or  poor  farm  house,  not  a  bath  tub  in  miles,  no 
clean  bed  linen,,  no  decent  drinking  water,  no  chance  of  proper 
food  or  good  nursing,  and  an  unalterable  opposition  to  hospitals 
in  general.  It  is  in  these  cases,  gentlemen,  that  we  have  to  prac- 
tice, for  it  is  only  amongst  such  that  we  see  most  of  our  severe 
malarias,  and  if  quinine  were  a  specific  they  would  all  be  cured 
before  we  ever  see  them.  They  all  take  plenty  of  quinine  dis- 
solved in  water,  and  with  it  calomel. 

I  have  tried,  in  the  severer  cases,  quinine  intra-venously,  and 
must  say  that  it  does  act  well,  that  it  is  the  only  way  to  give  it 


VAN  MAUTER.-QUIKINE  IN  MALARIA. 

in  the  severest  forms,  but  it  does  not  shorten  the  course  of  the 
fever;  it  seldom  breaks  it  up,  as  it  should,  if  it  were  a  specific. 
Were  it  not  beyond  the  scope  of  this  paper  I  should  have 
enjoyed  relating  my  experiences  this  summer  and  fall  in  the 
treatment  of  some  severe  cases;  in  fact,  I  am  preparing  a  paper 
on  the  results  obtained  by  using  the  formula  used  by  Wood- 
bridge  and  others  in  the  treatment  of  typhoid  fever.  I  was 
very  much  struck  by  the  uniformly  happy  results  obtained,  and 
in  many  instances  never  used  quinine  from  beginning  to  end 
of  the  fever;  commencing  it  in  convalescence  on  two  grain 
doses  three  times  a  day.  I  should  like  to  see  the  subject  of 
treatment  taken  up  by  this  Clinical  Society,  as  I  should  the 
prevention  of  malaria.  If  practitioners  of  experience  around 
here  are  not  competent  to  speak  on  the  treatment  of  maliria, 
who  could  be? 

I  am  one  of  those  who  believe  that  quinine  is  seldom  properly 
administered.  It  is  noi  the  amount,  but  the  way  you  give  it 
that  counts.  Give  it  with  an  acid  if  the  stomach  will  stand  it, 
or  else,  if  you  still  desire  to  give  it  by  the  m>jiith,  give  it  in  the 
effervescing  form  recommended  by  Burney  Yeo.  I  quote  from 
him  as  follows:  "We  may  state  in  this  connection,  that  we 
have  found  the  efficacy  of  quinine  in  febrile  states  very  much 
influenced  by  its  mode  of  administration.  If  we  prescribe  qui- 
nine dissolved  in  citric  acid,  and  given  in  effervesence  by  add- 
ing it  to  an  alkaline  mixture,  doses  of  two  to  three  grains  exert 
a  powerful  antipyretic  influence  far  greater  than  that  obtained 
by  the  same  quantity  of  quinine  given  in  dry  state.  We  have 
seen  abundant  reason  to  believe  that  in  infective  fevers,  if  qui- 
nine be  given  in  saline  solutions,  it  is  the  most  active  and  reli- 
able anti-toxine  we  at  present  possess."* 

The  use  of  strong  decoctions  of  lemon  in  the  early  morning 
is  a  very  useful  remedv,  but  I  cannot  branch  out  to  speak  of  its 
action,  because  that  would  be  exceeding  the  limits  of  mv  sub- 
ject. 

There  is  one  way  of  giving  quinine  by  the  mouth  of  particular 
efficacy  in  many  of  the  severe  varieties,  and  that  is  Warburg's 
Tincture,  and,  to  my  mind,  it  is  a  most  excellent  medicine. 

One  very  strange  observation  that  I  have  made  is  worth  relat- 
ing. I  had  a  patient  with  occasional  severe  attacks  of  malaria, 
who,  for  some  reason  or  other,  never  seemed  to  get  the  physio- 
*Burney  Yeo,   Clinical  Therapeutics,  Vol.  xi.  page  637. 


VAN  MARTER.-QUININE  IN  MALAPJA .  y  j 

logical  effects  of  quinine,  in  other  words,  he  never  had  ringinp; 
in  the  ears.  Thinking  that  the  quinine  was  not  being  absorbed 
pioperly,  although  I  had  given  it  in  various  ways,  I  gave  him 
several  hypodermics,  bv  the  method  I  shall  further  on  describe, 
and  failing  in  this,  I  pat  liim  on  big  doses  of  the  Warburg's 
Tincture,  and  strange  to  say,  ong  ounce  of  Warburg's  Tincture 
made  his  ears  ring.  This  extraordinary  phenomenon  has  often 
been  a  source  of  perplexity  to  me,  and  in  reasoning  about  it,  I 
have  come  to  the  conclusion  that  something  in  this  compound 
may  act  in  a  sli,p-ht  measure  as  an  antitoxine,  or  in  some  way  so 
modify  the  chemistry  of  the  blood,  as  well  as  the  activity  of  tlie 
glandular  and  eliminative  system,  as  to  give  quinine  a  chance.  Is 
it  not  true  perhaps,  that  quinine  meets  -vith  resistance  in  the 
blood  which  is  in  some  way  modified  by  that  complicated  mix- 
ture— Warburg's  Tincture?  Gentlemen,  this  is  a  very  interest 
ing  subject  upon  which  much  remains  to  be  known. 

Warburg's  Tincture  should  always  be  given,  as  recommended 
by  the  experienced  practitioners  in  India,  after  a  brisk  purge, 
undiluted,  in  doses  of  half  ounce,  all  drinks  withheld,  repeated 
in  three  hours,  and  the  patient  carefully  rolled  up  in  blankets  to 
encourage  the  profuse  aromatic  perspiration  which  follows.  It 
is  one  of  the  most  powerful  diaphoretics  known;  it  is  also  a 
diuretic,  a  stimulant  and  a  purgative.  I  always  follow  its  use 
by  opium,  and  small  doses  of  whiskey,  at  least  never  omic  the 
opium,  which  I  believe  acts  most  happily.  Recently,  I  have 
used  the  powdered  Warburg's  Tincture  put  up  \\\  elastic  cap- 
sules, by  Messrs  Parke,  Davis  &  Co., an  elegant  preparation,  far 
more  agreeable  to  the  patient  than  the  liquid,  but  I  am  iarfrom 
convinced  that  it  compares  to  the  liquid  preparations  obtainable 
in  England,  for  our  American  preparations  of  the  liquid  do  not 
act  as  well  as  the  English. 

Quinine,  by  the  rectum,  1  do  not  favor,  and  shall  not  speak 
of  to  night,  nor  shall  I  say  anything  about  inunctions,  for  that  is 
a  very  uncertain  way  of  giving  it,  but  of  the  hypodermic  method 
I  am  a  great  advocate.  In  giving  quinine  subcutaneously,  let 
me  urge  you  to  use  it  in  free  solution,  and  not  stick  to  your 
small  hypodermic  syringes.  I  am  nov/  using  what  is  usually 
called  an  "antitoxin"  syringe  with  a  i6  c.  c.  capacity.  By 
makin;'-  a  very  dilute  solution  more  quinine  ispromply  absorbed. 


72  VAN  MAKTEE.-QmNmE  IN  MALARIA. 

and  there  is  absolutely  no  danger  of  abscess  or  painful  inflam- 
mations. ),You  should  not  use  an  acid  to  dissolve  the  quinine, 
as  is  advised  by  most  writers,  for  it  is  not  necessary,  and  is  very 
painful.  The  dihydrochlorateand  hydrobromate  of  quinine  are 
the  two  salts  best  adapted  for  such  use,  and  also  for  intra- 
venous injection.  The  water  should  be  hot,  about  ioo°F. ,  and 
the  needle  sharp.  Whenever  in  any  case  of  malaria  the  gastric 
symptoms  are  marked,  and  this  is  frequent,  use  the  hypodermic 
method  in  the  commencement.  You  are  then  sure  that  the  pa- 
tient is  getting  all  the  quinine  you  want  him  to  have  promptly, 
and  without  additional  burdens  on  the  stomach.  I  have  never 
seen  but  two  abscesses  (and  they  were  not  in  my  practice)  from 
hypodermic  injections  of  quinine;  one  due  to  an  excess  of  acid, 
the  other  to  a  filthy  syringe.  Don't  inject  in  the  arms.  The 
belly  wall  is  a  very  handy  place  to  inject  your  solutions,  and 
never  bothers  the  patient,  like  it  does  in  the  thighs  or  back. 
Use  from  8  to  lo  grains  at  each  injection,  and  if  the  quinine 
does  not  work  promptly  don't  pin  too  much  faith  to  it,  nor  that 
absurdity  called  the  therapeutic  test — a  relic  of  barbarity. 

Intra-venous  injections  of  quinine  you  are  all  more  or  less 
familiar  with,  at  least  as  regards  technique,  which  is  simple, 
but  I  find  a  good  deal  of  hesitation  amongst  a  great  many  phy- 
sicians as  to  its  use.  Fear  of  its  difficulty,  of  slipping  up  in 
asepsis  or  admitting  air  into  the  veins;  all  points  easily  avoided 
and  overcome.  Having  been  brought  up,  you  might  say,  on 
this  method  of  using  quinine,  and  having  seen  its  development 
in  the  Santo  Spirito  Hospital,  Rome,  in  the  service  of  the  Bac- 
celli,  I  have  had  very  good  opportunities  of  seeing  it  practised. 
Here,  as  elsewhere  in  this  paper,  I  shall  have  to  remind  you  that 
as  this  is  not  apaper  onthe  treatment  of  malaria,  I  must  refrain 
from  describing  the  method,  its  indications,  advantages,  but 
simply  its  action. 

We  get  by  an  ordinary  injection  what  for  the  blood  is  a  very 
large  amount  (15  grain?),  and  I  honestly  believe  that  if  we  could 
see  our  cases  early  enough,  all  cases  of  pernicious  malaria  of  a 
fulminating  type  could  be  saved;  but  alas!  we  seldom  see  them 
early,  for  such  cases  come  in  town  from  the  country  "in  ex- 
tremis"— that  at  least  is  the  common  experience  in  Rome.  Once 
the  Plasmodium  have  had  time  to  fully  manufacture  their  toxine, 


VAN  MARTER.-QUININE  IN  MALARIA.  -, 

it  is  too  late  to  rely  on  quinine.  As,  however,  I  have  seen 
several  cases  recover  after  intra-venous  injections  in  the  last 
stages,  you  may  well  ask  how  it  is  that  they  did  not  die  too. 
Gentlemen,  I  attribute  a  good  share  of  some  (not  all)  the  recov- 
eries to  ihe  happy  effects  of  quinine,  but  some  are  due  to  the 
salt  solution  injected  at  the  same  time.  It  has  never  yet  been 
done  by  control  experiments,  but  I  have  no  doubt  that  if  you 
gave  some  of  these  cases  a  large  intra-venous  injection  of  normal 
salt  solution,  say  20  ounces,  and  no  quinine,  you  would  get  as 
good  results  as  you  could  by  quinine.  I  know,  from  experience,  that 
this  will  start  secretion  in  the  kidneys,  the  only  channel  by  which 
the  poison  escapes  in  this  condition.  Any  observing  man  whose 
misfortune  it  has  been  to  have  a  number  of  severe  pernicious 
malaria  cases  in  his  practice,  will  agree  with  me  when  I  st»te 
that  if  you  can  set  up  diuresis,  sweating  and  purging,  while  vig- 
orously stimulating  the  patient,  he  is  apt  to  live,  quinine  or  no 
quinine;  and  on  the  other  hand,  without  this,  but  all  the  quinine 
you  please,  the  patient  will  die.  It  is  the  common  experience 
we  have  with  every  poison  from  malaria  to  rattlesnake  bite. 

Let  us  not  say  a  thing  is  so  because  the  books  written  by 
great  teachers  say  it  is  so.  Let  us  observe,  reason  and  then  if 
we  are  not  satisfied  of  the  accuracy  of  a  statement  let  us  say  so. 
The  last  words  have  not  yet  been  spoken  on  the  specific  action 
of  quinine  in  malaria  (in  our  climate),  and  in  the  same  breath  I 
will  say  the  book  on  malaria  has  not  yet  been  written.  I  know 
quite  well  that  there  will  be  wailing  and  gnashing  of  teetli  over 
the  presumptiousness  which  could  question  the  specificity  of 
quinine,  but  the  truth  will  out,  and  I  feel  confident  that  many 
will  agree  with  my  views  on  this  subject. 
To  summarize  briefly  my  conclusions  are: 

1.  As  a  preventive  quinine  will  not  do  for  those  who  are  com- 
pelled to  live  indefinitely  in  a  severe  malarial  climate,  in  time, 
acting  as  a  vaso-motor  poison. 

2.  Quinine  acts  nearly  as  a  specific  in  all  malarial  fevers  char- 
acterized by  intermissions  or  well  marked  remissions,  but  fails 
in  continued  fevers,  those  with  typhoid-like  symptoms,  those 
malarias  witliout  temperature,  and  the  cachexias  and  anemias 
due  to  malaria. 

3.  Proving  thus  that  quinine  is  a  poison  to  the  Plasmodium 
itself,  but  useless  against  the  toxine  manufactured  by  it. 


.,  .  RIDDICK-.IN  THE  MATTER  OF  DOCTORS  AND  PANTS. 

4.  That  Warburg's  Tincture  in  the  last  condition  has  an  action 
not  yet  understood,  on  the  toxine  (or  eliminative  system)  by 
which  the  system  is  put  in  condition  to  benefit  by  quinine. 

5.  That  quinine  should  never  be  used  in  haemoglobin uria,  or 
given  subsequently,  to  one  who  has  suffered  from  it,  being 
liable  to  bring  about  a  recurrence  of  the  condition. 

6.  Only  those  living  in  regions  of  severe  malarias  can  be- 
come competent  to  settle  these  questions  pro  or  con. 


IN  THE  MATTER  OF  DOCTORS  AND  PANTS. 
By  Thos.  M.  Riddick,  M.D.,  Woodville,  N.  C. 

"Lives  of  doctors  all  remind  us. 
Honest  work  don't  stand  no  chance; 
The  more  we  work  there  grow  behind  us. 
Bigger  patches  on  our  pants; 
On  our  pants  once  new  and  glossy. 
Now  of  stripes  of  varied  hue, 
All  because  the  patients  linger, 
And  wont  pay  up  what  is  due. 
Then  let  us  all  be  up  and  doing, 
Bring  your  cash,  however  small, 
Or  when  snows  of  winter  strike  us. 
We  shall  have  no  pants  at  all." 

— Paraphrased  from  McBeechy, 

WHAT  a  sad  lugubrious  suggestion  is  contained  in  those 
touching  pathetic  lines.  The  very  thoughtof  it  appalls 
us.  It  causes  chills  of  nervous  origin  to  make  com- 
petitive foot  races  up  and  down  our  spinal  ridge.  It  suggests 
to  us  the  primitive  costume  of  a  gentlemen  who  is  about  to  go 
in  swimming,  while  dark  and  angry  looking  clouds  are  dropping 
their  fleecy  whiteness  down. 

How  any  christian  soul,  living  in  the  light  of  latter-day  civi- 
lization, can  with  equanimity  contemplate  a  patient,  self-sacri- 
ficing doctor  without  pants,    must   be   alike  revolting  and   in- 
comprehensible to  every  humanitarian  heart. 
Quis  est  homo  qui  non  fieret, 
Bonum  doctorem  si  videret, 
In  tauto  supplicio. 


RIDDICK.-IN  THE   MATTER  OF  DOCTOR  AND  PANTS.  ^c 

Yet,  looking  the  cold  hard  facts  straight  in  the  face,  and  dis- 
carding every  trace  of  maudlin  sentiment,  such  a  catastrophe 
seems  a  naked,  chilling  possibility,  in  these  Bill  McKinley  times. 

Of  all  the  earnest  workers  in  life's  rugged  battle  there  is  no 
man  who  toils  more  faithfully  for  the  relief,  the  betterment,  and 
material  advancement  of  his  kind,  than  the  conscientious  hard- 
working doctors.  He  visits  alike,  with  cheerful,  willing  step, 
the  palace  of  the  magnate  and  the  hovel  of  the  pauper.  He 
goes  as  an  angel  of  mercy,  bearing  strength  and  healing  in  his 
wings,  into  these  squalid  haunts  where  degredation  and  suffer- 
ing are  the  heritage  of  the  illstarred  inmates,  and  where  dire 
want  is  the  cruel  regent  that  sways  a  tyrant's  sceptre  over  the 
unhappy  wretches  that  crowd  his  dirty  dominion.  Yet  to  the 
humanitarian  doctor,  the  man  who  aspires  to  the  role  of  the  true 
physician,  of  which  the  loved  and  lamented  J.  Lewis  Smith  is  a 
noble  and  immortal  example,  it  is  ever  a  labor  of  love  to  miti- 
gate the  miseries  of  the  unfortunates  about  him,  and  to  let  in 
the  sunlight  of  health  and  hope  where  disease  and  despair  had 
cast  their  baneful,  depressing  shadows. 

When  one  realizes  what  "a  shield  and  buckler  and  very  pres- 
ent help  in  time  of  trouble"  the  good  doctor  is  to  a  suffering  pa- 
tient, how  he  alone  has  that  scientiaor  professional  gift  by  which 
pain  may  be  relieved  in  the  hour  of  agony,  fears  allayed,  and  a 
new  lease  given  to  life  by  the  therapeutic  removal  of  morbific 
causes  that  are  actively  at  work  dealing  out  wretchedness,  and 
threatening  death  to  those  who  have  fallen  as  victims  to  their 
insidious  approaches,  it  is  a  matter  of  surprise,  as  well  as  re- 
gret, that  the  rank  and  file  of  humanity  are  not  more  thor- 
oughly aroused  to  an  appreciative  sense  of  the  physician's  use- 
fulness and  worth,  as  a  helpful  member  of  the  body  politic. 
Yet  the  perversity  of  human  nature  is  such,  and  the  dominating 
force  of  ingratitude  is  so  great  in  many  human  hearts,  that  the 
once  helpless  beneficiaries  ot  the  physician's  healing  art  are  often 
among  the  first  to  not  only  refuse  him  a  reasonable  compensa- 
tion for  valuable  services  rendered,  but  will  willingly  join  in  an 
assault  upon  his  professional  character,  and  speak  the  words  of 
destruction  and  slander,  where  only  terms  of  heartfelt  apprecia- 
tion and  lasting  gratitude  should  be  heard.  Those  worthies  are 
not  unlike  the  fat  and  greasy  porker,  who  never  looks  up  to  the 


yg  RIBDTCK  -IN   THE   MATTER   OF  DOCTOR    AND  PANTS. 

Stately  and  beneficent  oak   that  kindly  sheds  the  strengthening 
acorns  down,  for  his  maintenance  and  support. 

These,  and  a  few  other  random  kindred  thoughts,  occuned  to 
me,  a  few  days  since,  while  out  makiug  a  collecting  tour  among 
my  patrons.  A  patient  of  mine,  who  for  the  sake  of  euphony, 
we  will  call  Mr.  Jones,  was  feeling  the  first  return  of  that  strength 
and  vigor  which  are  incident  to  restored  health.  He  had  passed 
through  a  trying  and  severe  ordeal  of  typhoid  fever  of  several 
weeks  duration.  During  his  long  continued  sickness,  fearing 
that  I  might  possibly  be  somewhat  remiss  in  my  professional 
attentions,  because  of  the  length  of  his  attack,  and  the  trouble 
and  cost  incident  to  making  many  visits,  he  often  endeavored 
to  encourage  me  with  the  promise  of  several  bushels  of  wheat, 
which  he  would  sell  me,  telling  me  that  in  the  purchase  of  it  I 
should  have  the  preference  over  all  other  prospective  buyers. 
I  listened  to  his  siren  song  with  child-like  good  faith.  When  I 
called  upon  him  some  time  afterwards  to  execute  his  oft  re- 
peated promise,  and  make  actual  delivery  of  the  wheat,  he  as- 
phyxiated me  by  telling  me  that  he  had  decided  to  deliver  the 
wheat  to  a  neighboring  buyer,  but  that  /  should  have  the  pref- 
erence ! 

This  is  perhaps  a  comic  yet  a  typical  picture  of  many  expe- 
riences which  doctors  often  encounter.  Of  course  it  is  not  inti- 
mated for  a  moment  that  all  patients  settle  on  that  shadowy, 
non-s'jbstantial  basis,  for  there  are  many  true  and  loyal  men 
who  delight  to  render  timely  and  needed  aid  to  the  family  doc- 
tor, and  they  do  so,  not  only  as  a  business  obligation  and  duty, 
but  as  a  practical  evidence  of  personal  regard  and  sincere  ap- 
preciation of  the  physician's  kindly  and  helpful  ministrations  to 
them  and  theirs,  when  suffering  was  great  and  danger  nigh. 
For  those  worthy  good  fellows  every  doctor  holds  a  sentiment 
of  respect  and  regard  second  only  to  that  which  Damon  showed 
for  Pythias. 

The  most  distressing  feature  about  this  unfortunate  and  un- 
happy status  of  affairs  is,  that  under  present  existing  conditions, 
there  appears  but  little  remedy  or  relief  available.  In  many  lo- 
calities doctors  are  like  farmers,  in  that  they  do  not  work  to- 
gether for  their  reciprocal  good.  While  they  might  by  unity  of 
action,  and  judicious  self-protective  measures,  accomplish  much 


RIDDICK.-IN  THE  MATTER  OF  DOCTOR  AND  PANTS.  ^y 

for  the  betterment  of  their  finances,  they  unfortunately  permit 
a  spirit  of  rivalry,  competition  and  self  seeking  to  abort  and 
annul  the  mutual  benefits  which  would  result  from  concert  of 
action.  Oft  times  a  younger  brother  of  the  craft  will  willingly 
serve  professional  and  veteran  leg  pullers,  that  are  found  on 
most  every  doctor's  black  list,  and  they  encourage  that  class  of 
frauds  in  their  nefarious  designs,  for  that  genus  will  never 
settle  with  an  old  medical  creditor  if  a  young  and  unsuspecting 
practitioner  is  at  hand,  whom  they  can  fall  and  utilize.  The 
matter  of  age  and  experience,  in  professional  work,  cuts  no 
figure  with  them,  for  a  vender  of  rostrums,  or  a  huckster  of 
"worm  oil,"  if  dubbed  "Doctor,"  would  serve  them  as  well  as 
Dr.  Horatio  C.  Wood,  or  Prof.  Hobart  Amory  Hare. 

There  are  few  classes  of  business  men  and  workers  who  do  not 
have  well  perfected  organization,  by  which  they  are  protected 
from  the  encroachments  and  unfair  designs  of  those  with  whom 
they  have  business  relations,  and  I  take  it  that  it  is  not  beneath 
the  dignity  and  rank  of  our  own  noble  profession,  to  take  such 
co-operative  and  protective  measures  as  will  give  them  immu- 
nity from  the  hurtful  machinations  of  those  who,  while  they  are 
able  to  pay,  will  not  do  so,  because  of  total  dishonesty  and  lack 
of  principle. 

No  doctor  of  character  anc  proper  feeling  ever  refuses  either 
medicine  or  service  to  the  really  mdigent  and  needy,  but  there 
IS  not  an  element  of  charity  in  serving  and  encouraging  a  class 
of  dishonest  vampires  who  ultimately  despise  those  whom  they 
have  leeched. 

If  some  gentleman  of  experience  and  influence  in  our  State 
Medical  Society  could  be  induced  to  take  the  initiatory  steps  in 
a  movement  for  the  prosecution  of  such  a  measure,  even  through 
legislative  aid  and  interference,  it  might  result  in  great  good  to 
many  worthy  and  deserving  practitioners. 


NORTH  CAROLINA  MEDICAL  JOURNAL, 

ROBERT  D.  JEWETT,  M.D.,  Editor. 


DEPARTMENT  EDITORS. 


(  H.  T. 
\  R.  L. 
(      J.  Ho 


Bahnson,  M.D.,  Salem,  N.C. 
SURGERY:     -J      R.  L.  Gibbon, M.D.,  Charlotte,  N.  C. 

r.  Howell  W  ay,  M.D.  ,  Waynesville,  N.  C. 

NERVOUS  DISEASES:— J   llison  Hodges,  M.D.,  Rcihmond,  Va. 
PRACTICE  OF  MEDICINE.  ]    ^^  ^ISeviUe!™'.  ^'^"  ^'  ^'  ^" 

nucrpr^oTno.      I      Geokge  G.  Thomas,  M.D.,  Wilmington,  N.  C. 
OBbiEiKlCb.     -j     j^  L.  Payne,  M.D.,  Norfolk,  Va. 

(      H.  S.  LOTT,  M.D.,  Winston.  N.  C. 
GYNAECOLOGY:     \     J.  W.  LONG.  M.D.,  Salisbury,  N.  C. 
(     H.  A.  Royster,  M.D.,  Raleigh,  N.  C. 

PATHOLOGY:— Albert  Anderson,  M.D.,  Wilson,  N.  C. 
TRANSLATION  AND  FOREIGN  REVIEWS: 
Richard  H.  Whitehead,  M.  D.,  Chapel  Hill,  N.  C. 

This  Journal  is  published  on  the  fifth  and  twentieth  of  each  month,  and 
any  subscriber  tailing  to  receive  his  copy  promptly,  is  asked  to  announce  the 
fact  to  this  office. 

Cuts  will  be  provided  for  any  original  communications  (sent  to  this  Jour- 
nal only)  requiring  illustrations,  free  of  cost  to  the  author. 

Secretaries  of  County  Medical  Societies  in  the  Carolinas  are  asked  to 
furnish  condensed  reports  of  their  meetings  to  the  Journal. 

All  communications,  either  of  a  literary  or  business  nature,  should  be 
addressed  to,  and  any  remittances  by  P.  O.  Order,  Draft  or  Registered  Let- 
ter, made  payable  to  Robert  D.  Jewett,  M.D.,  P.  O.  Drawer  825,  Wilming- 
ton, N.  C. 


EMtodaL 


CAN  MAKE  IT  A  BOY. 

The  daily  papers  have  stirred  up  the  general  public  very 
greatly  by  publishing  the  claim  of  one  Dr.  Schenk,  that  he  is 
able  to  control  the  sex  of  offspring.  Dr.  Schenk  is  said  to  be 
a  teacher  of  embryology  in  the  Royal  and  Imperial  University 
of  Vienna  and  for  thirty  years  has  studied   that    department  of 


liJjrruKiAL,.  ~  g 

science  which  relates  to  rudimentary  creatures  in  their  prenatal 
existence.  He  claims  (a)  that  the  sex  of  the  chilk  when  it  is 
born  is  influenced  solely  and  entirely  by  the  mother;  (d)  that 
during  several  stages  of  its  development  the  child  unborn  is 
neither  male  nor  female,  but  sexless;  (c)  that  a  man's  blood  con- 
tains one-fifth  more  corpuscles  than  a  woman's  ;(</)  the  difference 
in  the  number  of  'corpuscels  in  the  blood  of  a  man  and  of  a 
woman  is  the  basis  not  only  of  the  difference  of  sex,  but  of  the 
normal  and  physical  working  powers  of  man  and  woman;  {e) 
that  if  the  larger  number  of  corpuscels  can  be  produced  in  the 
child  before  birth  it  will  be  male;  (/)  that  this  proper  number 
can  be  produced  by  giving  proper  food  to  the  mother.  He  as- 
serts that  in  the  case  of  single  births  he  can  assure  the  birth  of 
a  mak,  and  in  case  of  multiple  births  that  the  majority  will  be 
males.  Dr.  Schenk  does  not  disclose  the  nature  of  the  food 
which  will  accomplish  this  long-desired  end.  We  suppose  the 
next  thing  we  hear  of  in  this  connection  will  be  the  advertising 
circulars  from  some  enterprising  concern  announcing  that  Dr. 
Schenk  has  entrusted  to  it  the  preparation  of  "Schenk's  food" 
which  will  ensure  the  birth  of  a  boy.  At  any  rate  a  hitherto  in- 
conspicuous man  has  attained  an  evanescent  notoriety  and  the 
papers  have  given  the  dear  people  something  to  talk  about  f  (or) 
a  d  (ay). 

We  have  learned,  since  writing  the  above,  that  Dr.  Schenck 
has  succeeded  in  disposing  of  the  German  right  for  $10,000, 
and  will  not  disclose  his  secret  until  he  has  sold  the  American 
and  English  rights.     This  discloses  the  milk  in  the  cocoanut. 


SMALL-POX. 


In  the  last  issue  of  the  journal  we  noted  the  occurrence  of 
one  well-developed  case  of  small-pox  in  this  city,  and  a  second 
case  which  was  considered  suspicious.  Further  observation  con- 
firmed the  diagnosis  of  small-pox  in  the  latter,  and  the  patient, 
a  negro  man,  was  sent  to  a  house  without  the  city  limits,  and 
placed  in  the  care  of  an  immune  nurse.     The  first  case,  after  the 


gQ  EDITORIAL. 

refusal  of  the  mob  to  allow  our  staunch  city  authorities  to  place 
him  in  either  of  the  places  they  had  selected  for  him,  has  re- 
mained where  he  was  first  discovered.  He  will  be  discharged  in 
a  few  days.      The  second  case  is  also  convalescing. 

At  a  meeting  of  the  city  Board  of  Aldermen  held  on  the  24th 
of  January,  about /a/^  weeks  after  the  first  case  was  reported^  an 
ordinance  was  passed  requiring  compulsory  vaccination  of  all 
unprotected  persons.  Five  physicians  were  appointed,  at  a 
salary  of  $25.00  a  week,  to  perform  this  work.  Immediately 
the  fighting  spirit  of  the  mob  was  again  aroused,  and  mass  meet- 
ings have  been  held  each  night  since  the  enactment  of  the  ordi- 
nance, at  which  inflammatory  speeches  are  made  and  "give  me 
liberty,  or  give  me  death"  resolutions  are  adopted  and  presented 
to  the  Mayor,  who,  by  the  way,  is  a  physician.  What  the  result 
will  be  we  do  not,  of  course,  know,  but  rather  suspect  that  it 
will  be  a  victory  for  the  "patriots."  At  any  rate  the  public  vac- 
cinators are  hardly  earning  their  salt. 

The  trouble  about  the  whole  matter  is,  that  the  Board  of 
Health  does  not  possess  any  mandatory  power;  it  can  only  ad- 
vise,and  leave  the  rest  to  a  weak-legged  set  of  politicians.  Some 
of  the  Board  of  Aldermen,  in  their  antagonism  to  the  compul. 
sory  vaccination  ordinance,  even  went  so  far  as  to  doubt  the 
diagnosis  in  both  cases  reported,  and  to  use  as  an  argument  the 
jocular  remark  of  some  wag  that  "the  whole  scare  was  a  scheme 
on  the  part  of  the  physicians  to  increase  their  receipts."  If  the 
ordinance  foi  compulsory  vaccination  had  been  passed  imme- 
diately upon  the  occurrence  of  the  first  case,  there  would  have 
been  but  ,ew  persons  to  object  to  it;  but  the  small-pox  scare  has 
now  been  converted  into  a  vaccination  scare,  because  theunvac- 
cinated  have  witnessed  the  slight  inconvenience  suffered  by  those 
who  have  submitted  to  the  operation.  But  even  if  the  ordinance 
had  been  adopted  at  once  it  would  have  been  impossible  to  ob- 
tain a  sufficient  quantity  of  vaccine  to  promptly  vaccinate  all  per- 
sons in  the  city;  and  herein  is  the  error  of  waiting  for  the  actual 
visitation  of  the  disease  before  resorting  to  this  simple  measure 
which,  experience  has  demonstrated  time  and  again,  reduces 
the  mortality  from  this  truly  horrible  pestilence  to  a  minimum. 

It  would  be  a  good  work  for  the  State  Board  of  Health  to  un- 
dertake the  task  of  educating  the   people  up    to  the  importance 


SOCIETY  REPORTS. 


of  vaccination,  and  ot  revaccination  on  the  appearance  of  small- 
pox in  their  neighborhood,  and  the  Board  should  be  aided  as 
much  as  possible  by  the  general  profession  in  their  daily   work. 


Society  1Rcport6, 

SEABOARD  MEDICAL  ASSOCIATION. 
Of  Eastern  Vcrginia  and  North  Carolina. 


Meeting  of  Organization   held   in  Norfolk,   Virginia,  January 
20  and   21,  1898. 

AS  announced  in  the  last  issue  of  the  journal  the  physi- 
cians of  eastern  Virginia  and  North  Carolina  met  in  the 
city  ot  Norfolk  on  the  20th  of  January  for  the  purpose  of 
forming  a  new  medical  association. 

The  meeting  was  held  in  the  rooms  of  the  Young  Men's  Chris- 
tian Association  and  was  called  to  order  by  Dr.  H.  M.  Nash,  of 
Norfolk.  An  appropriate  prayer  was  offered  by  Rev.  A.  S. 
Lloyd,  rector  of  St.  Luke's  church. 

Hon.  W.  R.  Mayo,  Mayor  of  Norfolk,  welcomed  the  visiting 
physicians  'n  behalf  of  the  city,  and  Dr.  Nash  on  the  part  of  the 
local  profession. 

Temporary  organization  was  effected  by  the  election  of  Dr. 
Nash  as  temporary  chairman  and  Dr.  J.  E.  Phillips,  of  Suffolk, 
as  temporary  Secretary. 

A  committee  on  permanent  organization  was  next  appointed 
by  the  chair,  constituted  as  follows:  Dr.  Ruflfin,  Norfolk;  Dr. 
White,  North  Carolina;  Drs.  Vanderslice,  Wood,  and  Cul- 
pepper,  Virginia;  Dr.  Riddick,  North  Carolina;  and  Dr.  Kellam, 
North  Carolina. 

A  committee  on  Membership  was  thus  appointed  :  Dr.  Gwath- 
mey,  Norfolk;  Dr.  Corbell,  Sunbury.  N.  C.  ;  Dr.  Causey,  Suf- 
folk, and  Dr.  Wright,  of  Churchland. 

Dr.  Ruffin,  of  Norfolk,  chairman  of  the  committee  on  Organ- 
ization, reported  a  constitution  and  set  of  by  laws  for  the  Asso- 
ciation, and  these  are  the  principal  provisions: 


o  SOCIETY  REPORTS. 

o2 

The  name  of  the  body  shall  be  the  Seaboard  Medical  Associa- 
tion, and  the  meetings  shall  be  two  in  number  of  two  days  each 
every  year.  One  meeting  is  to  be  on  the  second  Thursday  in 
January  in  Norfolk  city,  or  within  thirty  miles  of  it;  and  the 
second  one  is  to  be  on  the  second  Thursday  in  July  in  North 
Carolina,  at  a  place  to  be  hereafter  chosen. 

The  officers  of  the  association  are  to  be  a  president,  two  vice- 
presidents,  secretary  and  treasurer.  One  of  the  vice-presidents 
is  to  be  chosen  from  Virginia  and  one  from  North  Carolina,  and 
it  is  recommended  that  the  code  of  ethics  of  the  American  Med- 
ical Association  bt  adopted  dy  this  association. 

No  papers  which  have  been  published  are  to  be  read  by  mem- 
bers of  the  association  before  it  at  any  of  its  meetings. 

On  motion  of  Dr.  Lynch  the  report  was  adopted,  and  the  as- 
sociation adjourned  until  3:30  p.  m. 

It  was  4  o'clock  when  the  association  met  to  begin  its  after- 
noon session,  when  the  temporary  organization  of  the  morning 
was  continued. 

The  committee  on  membership  reported  that  the  physicians 
ninety-five  in  number,  who  registered, are  duly  eligible  for  mem- 
bership in  the  association,  and  this  report  was  adopted. 

An  election  for  permanent  officers  resulted  as  follows: 

President,  Dr.  J.  F.  Lynch,  of  Norfolk. 

First  Vice-President,  Dr.  Thomas  F.  Riddick,  of  Woodville, 
N.  C. 

Second  Vice-President,  Dr.  J.  H.  Peck,  of  Hampton.  Va. 

Secretary,  Dr.  J.  E.  Phillips,  of  Suffolk,   Va. 

Treasurer,  Dr.  L.  Gwathmey,  of  Norfolk,  V  .. 

The  following  papers  were  read  and  brought  out  interesting 
discussion : 

"Report  of  a  Caesarean  Section,"  by  Dr.  J.  T.  Nicholson, 
Bath,  N.  C. 

"Alkalinuria"  by  Dr.  G.  K.  Vanderslice,  Phoebus,  Va. 

"Typhoid  Fever  and  Its  Treatment"  by  Dr.  Thomas  M.  Rid- 
dick,  Woodville,  N.  C. 

"Our  Recent  Work  with  the  X  Ray"  by  Dr.  Southgate  Leigh, 
Norfolk,  Va. 

"Gonorrhoeal  Ophthalmia"  by  Dr.  A.  E.Wilson,  Norfolk,  Va. 

"Wet  Dressing  in  Minor  Surgery,"  by  Dr.  Lucien  Lofton, 
Emporia,  Va. 


SOCIETY  REPORTS.  g- 

"Report  on  Modern  Surgery  of  the  Rectum,"  by  Dr.  South- 
gate  Leigh,  Norfolk,   Va. 

"Appendicitis,  Its  Treatment  and  Results"  by  Dr.  Kirkland 
Ruffin,  Norfolk,   Va. 

"Chronic  Laryngitis,  Its  Causes  and  Results"  by  J.  F.  Wood- 
ward, Norfolk.    Va. 

"Uterine  Drainage,"  Dr.  L.  Lankford,  Norfolk,   Va. 

"Abnormal  Giowtli  in  the  Post-nasal  Region"  by  Dr.  H.  L. 
Myers,  Norfolk,   Vu. 

The  President  appointed  as  the  Executive  Committee  Dr. 
White,  of  North  Carolina,  Dr.  Parrish  and  Dr.  Lofton,  of  Vir- 
ginia. 

The  following  committees  were  also  appointed: 

Credentials — Drs.  Ruffin,  White  and  Xellum. 

Auditing  Committe — Drs.  Gary,  Grice  and  Sutton. 

Among  the  social  features  which  added  greatly  to  the  pleasure 
of  the  meeting  were  a  luncheon  served  at  the  Business  Men's 
Association  by  the  Lynnhaven  Oyster  Growers  and  a  banquet 
at  the  Atlantic  Hotel,  tendered  the  Association  by  the  Physi- 
cians of   Norfolk. 

At  the  banquet  it  was  "punch"  and  the  following  were  the 
toasts  proposed  by  Dr.  Lynch,  toastmaster  of  the  occasion: 

The  Medical  Profession,  Dr.  R.  H.  Parker,  of  Portsmouth. 

The  Country  Doctor,  Dr.  Thomas  M.  Riddick,  of  North  Caro- 
lina. 

The  Old  North  State,  Dr.  Payne,  of  North  Carolina. 

The  Old  Dominion,  Dr.  Nash  and  Dr.  Chiles,  of  Norfolk. 

The  Old  Doctor  and  the  New,  Dr.  J.  F.  Bryant,  of  Franklin, 
Va. 

The  Southern  Physician,  Dr.  Wright,  of  North  Carolina. 

The  Doctor's  Best  Friend,  Woman,  Dr.  L.  B.  Anderson,  of 
N(,rfolk. 

The  Trained  Nurse,  Dr.  Causey,  of  Suffolk. 

The  number  of  physicians  present  at  the  meeting  exceeded 
one  hundred,  and  all  returned  to  their  homes  much  pleased  with 
the  success  of  the  meeting  and  with  the  hospitality  of  ths  pro- 
fession of  Norfolk. 

The  next  meeting  will  be  held  on  the  second  Thursday  in 
July,  at  some  place  in  North  Carolina  to  be  named  later  by  the 
Executive  Committe. 


SURGERY. 

IN  cha;;);e  of 

H.  T.  Bahnson,  M.D.,  a.  L.  Gibbon,  M.D. 

J.  Howell  Way,  M  D. 


Foreign  Bodies  in  the  Am  Passages— The  Roentgen  Ray  in 
N.  C. — From  the  Charlotte  Observer  we  condense  the  following :  A 
little  girl  near  Concord,  N.  C,  was  supposed  to  have  swallowed  a 
small  open-ended  thimble.  She  had  great  difficulty  in  swallowing  and 
became  greatly  exhausted  from  suffering  and  inanition.  After  eight 
weeks  Dr.  Henry  Louis  Smith.  Professor  of  Physics  in  Davidson  Col- 
lege, by  means  of  the  X-Ray,  located  the  foreign  body,  not  in  the 
alimentary  canal  as  was  supposed,  but  in  the  trachea,  2i  inches  below 
the  larynx.  This  was  accurately  determined  by  passing  a  flexible  steel 
instrument,  probably  a  spiral  catheter,  through  the  oesophagus,  while 
the  observer,  with  the  fiuoroscope,  noted  the  fact  that  the  instrument 
passed  well  behind  the  thimble.  Under  anaesthesia,  a  tracheotomy 
enabled  the  operator,  Dr.  Misenheimer,  of  Charlotte,  to  grasp  and  re- 
move the  thimble  through  the -opening  in  the  trachea  The  writer  can 
appreciate  the  fulsome  flattery  bestowed  upon  the  lucky  operator  by 
the  reporter  of  the  newspaper,  when  he  remembers  that  his  first  opera- 
tion— the  removal  of  a  cockle-bur  from  the  windpipe  of  a  child — gained 
him  more  praise  from  the  laity  than  a  long  series  of  difficult  ope- 
rations. 

The  capacity  of  a  small  child,  for  hiding  in  unsuspected  recesses  of 
its  economy,  even  large  foreign  bodies  is  well  exemplified  by  a  recent 
experience  of  the  writer.  An  eleven  months  baby  while  crawling  upon 
the  floor,  picked  up  and  put  into  its  mouth  the  upper  ferule  of  a  large 
umbrella.  The  ribs  of  the  umbrella  had  been  detached  but  the  wire 
with  projecting  twisted  ends,  was  still  in  place,  making  a  rough  ob- 
ject, more  than  an  inch  in  diameter  and  half  an  inch  long.  The  mother 
endeavored  to  get  it  out  of  the  child's  mouth  with  the  finger,  but  nat- 
urally only  pushed  it  into  the  throat.  After  terrific  strangling  and 
gasping,  the  child  apparently  swallowed  the  ferule.  Four  weeks  later, 
it  was  found  in  the  posterior  nares,  but  it  could  not  be  removed  by  the 
way  it  went  in.  The  space  was  so  small  that  whenever  the  body  was 
pushed  towards  the  fauces,  the  glottis  was  occluded,  and  the  child  was 
unable  to  breathe.  The  soft  palate  was  therefoi'e  divided  in  the  cen- 
tre, from  before  backwards  until  the  object  could  be  grasped  with 
forceps.  There  was  no  serious  hemorrhage,  and  the  opening  in  the 
palate  needed  no  stitches  to  draw  it  together.  H.  T.  B, 

X-Ray  In  Its  Medico-Legal  Aspects.— That  the  legal  as  well 
as   the   medical    profession   know   how  to   utilize  to   advantage   the 


SURGEEY.  85 

Roentgen  Raj's  is  perhaps  not  surprising,  but  none  the  less  in- 
teresting. The  Medical  Record  (Jan.  8th,  1898,  p.  58)  states:  "A 
jury  in  Elmira  last  week  acquitted  of  murder  a  man  who  was  on 
trial  for  this  crime.  The  man  whom  the  accused  shot  was  said  to  be 
improving  a  month  after  the  shooting,  when  the  X-Rays  were  used  to 
locate  the  bullet  which  was  in  the  brain.  Death  followed,  and  the  de- 
fence alleged  that  the  death  was  the  result  of  the  action  of  the  Roentgen 
Rays,  and  that  the  wounded  man  would  certainly  have  lived,  had  no 
attempt  been  made  to  locate  the  bullet. "  H.  T.  B. 


The  Surgery  of  Typhoid  Fever.— With  regret  that  we  cannot 
transcribe  the  whole  article,  we  quote  from  Dr.  Hugh  M.  Taylor,  Pro- 
fessor of  Surgery,  Univ.  Col.  of  Med.,  Richmond,  Va.,  on  "The 
Surgery  of  Typhoid  Fever:" 

1st.  A  Convenient  Infusion  Apparatus.  "Into  the  open  vein  the 
sharp  point  of  a  glass  pipette  of  an  eye  dropper  was  fastened  by  a 
ligature,  and  the  other  end  of  the  pipette  was  fastened  in  the  end  of  a 
long  tube  attached  to  a  fountain  syringe.  This  quickly  improvised 
transfusion  (infusion?)  apparatus  acted  nicely.  By  the  time  as  much 
as  a  pint  of  fluid,  warm,  sterilized,  normal  salt  solution,  had  been  in- 
troduced into  the  vein,  the  pulse  was  full  and  strong,  and  the  intro- 
duction of  a  quart  in  all,  increased  the  volume  and  arterial  tension 
until  the  moribund  patient's  pulse  was  as  strong  as  that  of  any  of  the 
attendants." 

2nd.  Summary  of  the  Article.  "My  experience,  limited  it  is  true, 
while  intensely  impressing  the  idea  that  delay  is  fatal,  is  emphatically 
in  accord  with  those  who  hold: 

1.  That  perforating  typhoid  ulcer  can  be  and  should  be  diagnosed 
prior  to  the  development  of  local  or  diffuse  septic  or  fibrino-purulent 
peritonitis. 

2.  That  a  perforation  of  a  typhoid  ulcer  into  the  peritoneal  cavity 
means  the  discharge  of  virulent  septic  contents  in  quantities  far  too 
large  to  justify  the  hope  of  its  being  circumscribed  by  plastic  peri- 
tonitis . 

3.  Diffuse  septic  or  fibrino-purulent  peritonitis  with  inevitable  death, 
if  left  to  the  resources  ot  nature,  is  the  unvarying  result  of  this  com- 
plication of  typhoid  fever. 

4.  That  the  treatment  of  complete  typhoid  perforation  is  essentially 
surgical,  and  the  surgical  treatment  is  logically  conservative.  That 
the  treatment  of  uncontrollable  (typhoid)  hemorrhage  with  the  view  of 
preventing  immediate  danger  and  subsequent  increased  anaemia,  is 
probably  within  the  provision  of  rational  surgery.  Rectal,  cellular 
and  direct  transfusion,  (infusion,)  is  a  resource  of  great  value  in  the 
treatment  (a)  of  shock,  (b)  of  hemorrhage,  (c)  probably  of  ptomain 
poison. 

5.  That  the  death  rate  is  large  in  spite  of,  and  not  because  of  opera- 


gg  SL^RGERY. 

tive  interference,  and  in  comi)IeLe  typhoid  ulceration   is  increased  by 
each  hour  of  delay  in  i-esorting  to  operation. 

6.  That  the  mission  of  operative  interference  is  to  prevent  septic  and 
librino-purulent  peritonitis. 

7.  The  idea  should  be  impressed  that  the  time  often  conceded  by  the 
physician  as  warranting  operation,  i.  e.,  the  developed  condition  of 
diffused  peritonitis,  is  the  time  practically  conceded  by  the  surgeon  to 
be  too  late,  the  case  having  then  passed,  with  few  exceptions,  beyond 
the  province  of  rational  surgery. 

8.  Not  even  a  moribund  condition  should  excuse  as  for  abandoning 
patients  with  typhoid  perforation  since  suppurative  peritonitis  from 
just  as  desperate  sources  has  been  brought  within  the  scope  of  success- 
ful surgery  by  an  improved  technique. 

9.  The  statistics,  though  too  few  to  be  conclusive,  support  the  opin- 
ion that  timely  surgical  interference  is  conservative  rather  than  radi- 
cal. Of  fifty -two  cases  recorded,  seventeen  recovex'ed,  32.68  per  cent. ; 
or.  excluding  some  doubtfvil  cases,  of  forty-live  operations,  eleven  re- 
covered, a  percentage  of  24.44.  While  these  statistics  will  be  changed 
lor  the  worse  by  the  cases  it  has  been  my  misfortune  to  see,  ( as  shown 
in  the  body  of  the  article,  manifestly  too  late  for  hopeful  operative  in- 
terference.— H.  T.  B.  ).  there  are  doubtless  successful  cases,  reports  of 
which  I  have  not  seen,  to  offset  them,  and  with  a  due  appi-eciation  of 
the  possibilities  of  early  recourse  to  operation,  I  anticipate  markedly 
improved  statistic!-;  in  the  near  future.  The  technique  of  the  operation 
does  not  differ  from  that  in  vogue  in  the  treatment  of  intestinal  perfo- 
ration and  its  consequences  from  other  causes.  A  knowledge  of  the 
fact  that  the  perforation  is  in  a  majority  of  instances  single,  and  occurs 
in  the  ileum  within  eighteen  inches  of  the  ileo-coecal  valve,  enables  the 
surgeon  to  find  the  lesion  without  much  trouble. 

It  is  claimed  that  there  is  hardly  a  well  authenticated  case  of  gun- 
shot wound  of  the  bowel  with  recovery.  I  am  sceptical  as  to  the  cor- 
rectness of  the  diagnosis  of  complete  typhoid  perforation  with  recov- 
ery, certainly  in  the  absence  of  a  post  mortem.  Those  who  have  seen 
the  fluid  fecal  matter  pouring  out  of  the  perforation  will  appreciate 
how  small  must  be  the  chance  of  preventing  infection  in  any  other  way 
than  by  an  operation,  and  this  will,  I  think,  be  a  sufficient  appeal  to 
us  to  do  the  best  we  can,  by  operating  upon  even  the  most  desperate 
cases."  H.  T.  B. 

Treatmknt  of  Empyema. -Dr.  McKinnon  (Brit.  Med.  Journal),  re- 
porting four  cases  of  empyema  from  pneumonia  thus  details  his  plan 
of  treatment: 

The  treatment  of  empyema,  of  whatever  origin,  is  purely  surgical.  I 
have  mentioned  that  many  cases  have  been  reported  as  cured  by  aspi- 
ration, and,  though  I  have  never  relied  upon  aspiration  when  the  fluid 
in  the  pleural  cavity  is  purulent,  I  can  well  believe  that  aspiration  re- 


SURGERY.  gy 

sorted  to  early  in  the  case  may  wholly  cure.  I  have  found  this  mcti-.od 
most  successful  in  simple  effusion.  a.nd  would  resort  to  it  in  any  y.a]l- 
able  ca,se  of  empyema.  Hovvever,  in  luy  own  experience,  I  have  always 
made  a  simple  incision  between  two  ribs  and  introduced  a  fair-sized 
rubber-tube.  I  prefer  not  to  irri^-ate  the  cavity,  even  though  the  fluid 
be  offensive.  The  tube  should  be  short  and  fixed  securely  in  position. 
The  nature  of  the  case  must  determine  the  point  at  which  the  tube  is  to 
be  inserted  and  what  length  of  time  it  is  to  remain. 

The  empyema  may  be  limited  and  the  pus  cavity  not  large.  The 
proper  point  for  the  incision  is  v^here  the  needle  has  demonstrated  that 
pus  is  present,  whether  that  point  be  high  or  low,  at  the  back,  side,  or 
front  of  the  chest.  It  is  an  abscess  cavity,  and  should  get  the  mos':  di- 
i^ect  drainage  possible. 

[That  aspiration  early  resorted  to  will  produce  a  cure  in  a  consider- 
able proportion  of  cases  of  purulent  pleurisy  has  been  the  experience 
of  the  writer  after  twelve  years  general  practice  oa  the  mountain  pla- 
teau of  Western  N.  C.  One  of  the  most  typical  illustrations  occurred 
in  the  case  of  D.  B.  A.,  aged  20,  a  tall  slender  mountain  youth,  seen 
in  consultation  Avith  Dr.  Wilson,  of  Sonoma,  Jan.  4th,  1890.  Had  had 
lobar  pneumonia  four  weeks  previously,  did  fairly  well  until  third 
week,  when  right  pleural  cavity  filled  up.  Cathartics  and  diuretics 
seemed  to  avail  little.  Four  and  a  haU'  pints  ot  thick,  crea,.uy  pus  was 
removed  with  an  ordinary  trocar  ( it  being  the  only  instrument  at  hand 
and  the  patient  six  miles  in  the  country.)  Two  days  later  three  pints 
more  were  removed.  Without  further  treatment  applied  to  the  pleural 
cavity  the  case  made  an  excellent  recovery  without  any  re-accumula- 
tion of  pleural  secretion.  Four  years  later  the  individual  had  devel- 
oped into  a  strong,  active  man.  J.  H.  W. 

Shot-Grain  Wounds  of  the  Eye.— Dr.  Taylor,  (.Jour.  Am.  Med. 
Assn.)  after  a  more  or  less  critical  I'eview  of  the  literature  of  the  sub- 
ject and  reporting  illustrative  cases  concludes: 

1st.  That  shot-grain  wounds  of  the  eye  are  less  dangerous  than 
wounds  of  similar  severity  from  many  other  causes. 

2nd.  That  in  general  an  eye  wounded  by  shot-grains,  unless  the 
wound  be  one  of  unusual  ssverity  should  not  be  immediately  enuclea- 
ted, but  should  be  treated  conservatively  under  careful  observation. 

3rd.  A  patient  with  a  wound  of  this  character  should  i-est  in  bed  for 
a  period  of  two  weeks  or  more,  and  the  wound  be  treated  under  most 
rigid  antiseptic  precautions.  J.  H.  W. 

Carcinoma  of  the  Breast.— Dr.  W.  F.  Westmoreland  delivered 
the  President's  Address  upon  the  above  subject  at  the  recent  annual 
session  of  the  Tri-State  Med.  Society  of  Georgia,  Alabama  and  Ten- 
nessee. In  the  address  he  deplored  the  fact  that  cases  are  referred  to 
the  surgeon  too  late  for  operation.  He  called  especial  attention  to  the 
importance  of  early  diagnosis.     Every  tumor  the  breast  is  supicious. 


All  writers  agree  that  inflammation  of  the  breast  predisposes  to  cancer. 
Traumatism  plays  an  important  part  in  causation.  In  his  experience, 
when  there  is  a  bad  family  history,  the  tumor  will  return.  The  great- 
est infiltration  is  in  the  skin  next  the  subpectoral  and  axillary  glands. 
Cells  may  be  widely  scattered  early.  Everything  that  looks  suspicious 
in  the  axilla  should  be  removed.  Operation  should  be  complete  even 
to  excision  of  axillary  veins.  If  half  can  be  saved  it  will  be  as  good  as 
ean  be  expected.  No  living  man  can  lose  only  six  per  cent,  if  the  three 
years'  rule  is  observed.  Figures  are  fallacious.  All  cancer  patients 
have  a  lack  of  red  blood  corpuscles,  the  hsemaglobin  reduced  to  90  per 
cent. ;  when  the  hasmaglobin  reduced  15  per  cent,  patient  will  die.  This 
accounts   for   many  lost    after   operation   with  no    apparent  cause. — 

J.  H.  W. 

Special  Care  of  Sphincter  Ani  in  Operation  for  Fistula.— 

Dr.  N.  H.  Henderson  (Matthew's  Quarterly )  says  the  methods  of  ope- 
ration taught  by  the  text-books  include  complete  division  of  the 
sphincter  at  one  or  more  points,  and  the  surgeon  who  has  been  called 
upon  to  repair  such  a  sphincter  will  testify  to  the  hopelessness  of  the 
situation.  In  order  to  avoid  such  a  result  he  resorts  to  the  following 
technique:  The  sphincter  is  first  thoroughly  dilated  and  a  probe  intro- 
duced into  the  sinus  to  locate  its  course  and  internal  opening.  An  in- 
cision about  one  inch  long  and  half  an  inch  deep  is  then  made  upon 
each  side,  but  not  into  the  sinus,  these  incisions  remaining  parallel 
with  the  fibres  of  the  sphincter  and  care  being  taken  not  to  wound  that 
muscle  at  any  point.  This  done,  the  end  of  the  sinus  is  grasped  with 
forceps  and  dissected  out  intact.  The  internal  opening  is  then  dragged 
down  and  carefully  closed  with  fine  catgut. 

The  external  wound  is  now  thoroughly  irrigated  and  rendered  asep- 
tic, then  closed  with  deep  sutures  of  silkworm  gut,  a  bit  of  gauze  being 
placed  between  two  sutures  for  drainage.  In  the  event  of  more  than 
one  sinus  the  procedure  is  more  difficult.  But  if  we  will  remember  the 
origin  and  insertion  of  the  external  sphincter,  we  can,  if  necessary, 
completely  loosen  it  from  coccyx  to  perineum  and  dissect  out  the  un- 
derlying fistulous  tracts.  If  section  of  the  muscle  should  be  demanded 
it  should  be  made  in  the  median  line  posteriorly  and  after  the  sinus  is 
dissected  out,  the  muscle  at  once  repaired  by  suturing. 

Dr.  Henderson  has  used  this  method  during  the  past  two  years  and 
the  results  obtained  warrant  him  in  recommending  it  to  the  profes- 
sion.- J.  H.  W. 

The  Management  of  P.\tients  Before  and  After  Laparotomy. — Dr. 
Wiggin  (Med.  Record),  after  an  exhaustive  review  of  the  subject  deduces  the 
following  conclusions: 

1.  The  importance,  whenever  practicable,  of  prolonged  preparatory  treat- 
ment of  patients  about  to  undergo  an  abdominal  operation. 

2.  The  importance  of  the  administration  of  cathartics  in  the  earlv  part  of 


this  period,  followed  by  large  enemas  for  the  purpose  of  cleansing  the  inf?- 
tinal  tract. 

3.  The  importance  of  keeping  a  record  of  the  body  temperature,  respira- 
tion and  pulse-rate,  for  several  days  in  advance  of  the  operation,  and  of 
making  a  final  examination  of  the  urine. 

4.  The  necessity  in  the  female  of  arranging  to  have  the  operation  per- 
formed a  few  days  after  the  menstrual  period,  and  the  cleansing  of  the 
va^nna,  even  when  it  is  intended  that  the  operation  shall  be  by  the  abdomi- 
nal route  only. 

5.  The  administration  of  a  small  quantity  of  peptonized  food,  one  ounce, 
containing  stimulants,  two  hours  before  giving  the  anaesthetic,  for  the  pur- 
pose of  lessening  the  tendency  to  nausea  and  vomiting  after  the  recovery  of 
consciousness. 

6.  The  necessity  of  the  anaesthetic  being  given  by  an  experienced  physi- 
cian, and  in  the  smallest  possible  quantity. 

7.  The  necessity  of  protecting  the  patient's  body  properly  with  clothing 
and  blankets  during  the  operation. 

8.  The  advantage  of  stimulating  the  pulse  before  the  heart  has  become 
much  exhausted,  and  of  using  intravenous  saline  injections  before  the  radi- 
cal pulse  has  become  extinct. 

9.  The  leaving  in  the  abdominal  cavity  after  free  irrigation  of  a  quantity 
of  hot  saline  solution,  for  the  purpose  of  stimulating  the  patient,  preventing 
(?)  the  formation  of  intestinal  adhesion  and  lessening  the  danger  of  septic  in- 
fection of  the  peritoneum. 

10.  The  necessity  of  making  the  patient  comfortable  by  change  of  position 
during  the  first  two  days  of  convalescence,  and  by  the  use  of  the  rectal  tube. 

11.  The  necessity  for  the  early  administration  of  food  in  reasonable  quan- 
tities and  at  proper  intervals. 

12.  The  necessity  of  withholding  stimulating  enemata  after  operations 
in  which  extensive  and  firm  pelvic  adhesions  have  been  broken  up. 

13.  The  necessity  for  deliberation  as  to  the  wisdom  of  re-opening  the  peri- 
toneal cavity  in  a  given  case  of  supposed  concealed  hemorrhage. 

14.  The  importance  of  washing  out  the  stomach  as  soon  as  the  diagnosis 
of  intestinal  paresis  is  made,  and  of  the  persistent  use  of  saline  cathartics 
till  the  bowels  move, 

15.  The  importance  of  not  administering  cathartics  to  those  convalescing 
from  abdominal  operations,  and  who  are  pursuing  a  normal  course,  too  early 
or  in  large  doses.  J-  H.  \V. 


Corresponbence. 


'GASTRIC  FEVER."— A  REPLY  TO  DR.   HUNT. 


Editor  N.  C.  Medical  Journal: 

During  the  lattar  part  of  last  summer,  I  received  tlie    follow- 
ing note. 

Brevard  N.  C,  Aug.  20th,  1897. 
Dear  Doctor: — I  have  read  your  article  in  the  N.  C.  Medical 
fonrnal  ior  kugnsl  1897  on  "Our  Continued  Fevers  are  either 
Typhoid  or  Malarial."  We  have  a  fever  here  and  I  know  there 
is  no  malaria.  Please  read  in  Merck's  Bulletin,  April  1893,  p. 
273,  "Differential  Diagnosis  between  Typhoid  and  Gastric  Fever" 
The  article  is  signed  "Transylvania,"  the  name  of  my  county. 
Give  me  the  benefit  of  your  opinion  in  N.  C.  Medical  Journal 
after  reading  it.  Yours  truly, 

C.  W.  HUNT,  M.  D. 

I  wrote  to  Dr.  Hunt  for  a  copy  of  the  Bulletin  referred  to  and, 
along  with  it,  came  this  letter  from  him. 

Brevard,  N.  C,  Aug.  30,  1897. 
Dear  Dr.  Rovster: — In  this  mail  I  send  Merck's  Bulletin, 
containing  article,  Gastric  vs  Typhoid  Fever.  I  wrote  the 
ariicle  after  years  of  observation  at  the  bedside  of  symptoms 
and  course,  etc.,  of  the  fever  mentioned.  There  is  nothing  in 
a  good  many  names.  Typhoid  you  know  wasanly  called  by  that 
name  for  convenie  ice.  The  term  "gastric  fever"  used  for  the 
symptoms  and  the  disease  mentioned  could  possibly  be  called  by 
a  better  name.  My  ©bject  in  calling  attention  to  the  matter  is 
to  get  your  xxx  pen  at  work  in  either  proving  or  disproving  my  views, 
for  the  benefit  of  the  profession.  In  recording  the  group  of 
symptoms  as  I  have  done  I  was  not  biased  in  anyway;  would 
have  as  soon  called  it  typhoid  as  the  other  xxx,  though  I  did 
not  think  that,  if  one  grouping  of  symptoms  was  called  typhoid, 
it  would  be  scientific  and  correct  to  call  the  other  by  the  same 
name.  Sincerely  yours, 

C.  W.  HUNT. 


CORRESPONDENCE- 

My  delay  in  replying  to  these  very  courteous  communications 
of  Dr.  Hunt  has  been  owing  to  various  causes,— rush  of  work, 
absence  from  home  part  of  the  time  and  a  natural  tendency  to 
procrastinate.  At  this  late  hour,  I  wish  simply  to  give  my  opin- 
ion for  whatever  "benefit"  it  may  be,  at  the  same  time  disclaim- 
ing any  attempt  at  'Vither  proving  or  disproving"  the  views  of 
Dr.  Hunt  or  of  any  one  else.  A  few  remarks  on  the  article  and 
a  brief  statement  of  my  own  belief  in  the  matter  will  be  all  that 
is  necessary. 

First,  Dr.  Hunt  cannot  know  that  some  of  his  cases  were  not 
malaria,  unless  he  subjected  them  to  a  blood-examination.  It 
is  possible,  but  not  probable,  that  malarial  fever  exists  in  Tran- 
sylvania county.  Altitude,  salubrious  climate  and  a  rocky  soil 
are  not  necessa-ily  incompatible  with  malaria.  The  exclusion 
of  this  disease  from  the  cases  of  fever  which  he  describes  is  an 
essential  point  that  he  has  omitted  and  it  can  only  be  done  by 
a  microscopic  examination  of  the  blood.  This  question  may  be 
regarded  as  absolutely  settled.  Until  Dr.  Hunt  puts  another 
series  of  cases  to  this  scientific  test,  I  shall  not  be,  nor  do  I  see 
how  he  can  be,  satisfied  that  he  has  not  treated  some  cases  of 
malarial  fever. 

On  page  274  of  his  paper.  Dr.  Hunt  enumerates  what  he  re- 
gards as  "some  of  the  essential  characteristics  of  typhoid  fever," 
in  order  to  draw  a  sharp  distinction  between  that  and  "gastric 
fever."  These  essentials,  he  says,  are  the  slow  approach, 
"debility,  want  of  appetite,  bronchial  cough,  bleeding  at  the 
nose"  (these  being,  he  says,  almost  pathognomonic  symtoms), 
then  tympanites,  diarrhoea,  rose-spots,  tenderness  in  right  iliac 
region,  with  a  febrile  duration  of  three  to  six  weeks.  He  thinks 
that  "typhoid  i^y^x  cannot  be  arrested,  aborted  or  broken  up  in 
its  course."  The  temperature  is  considered  by  him  to  be  wor- 
thy of  "special  study."  "The  thermometer,  if  properly  read, 
will  say:  'Typhoid  fever' or  'no  typhoid  fever.'"  Further,  he 
says:  "This  is  such  a  ^^r/a/«  guide,  that  if  the  best  renowned 
physician  should  pronounce  a  case  'typhoid'  and  if  the  ther- 
mometer did  not  show  the  characteristic  readings — he  would  be 
compelled  to  abandon  his  preconceived  opinion  and  acknowledge 
to  himself  that  he  was  wrong." 

Now,  I  am  willing  to  admit    that  the   above   symptoms  are 


CORRESPONDENCE. 

characteristic  of  a  genuine  case  of  typhoid  fever.  If  a  patient 
presented  such  symptoms,  he  would  most  assuredly  have  a  u'cll 
marked  case  of  the  disease.  But  I  must  insist  just  as  forcibly 
that  he  could  have  typhoid  fever  and  not  show  all  those  char- 
acteristics— or,  indeed,  only  a  very  few  of  them.  It  must 
always  be  borne  in  mind  that  the  type  of  the  disease  varies  and 
there  is  some  reason  for  believing  that  it  changes  with  different 
periods  or  cycles.  In  the  last  few  years  it  is  certainly  not,  in 
this  section,  the  classical  malady  which  the  text-books  describe, 
nor  does  it  compare  here  with  the  type  which  I  saw  in  the  Northern 
hospitals  three  years  ago.  I  shall  not  try  to  discuss  at  this  time 
the  cause  of  tliis  modincation.  Whether  due  to  a  total  change 
cf  type  or  to  different  modes  of  management,  I  am  not  pre- 
pared to  say.  At  any  rate,  we  do  meet  with  a  typical  typhoid. 
Only  recently  I  noticed  in  a  discussion  before  the  Practitioners' 
Society  of  New  York  city  the  statement*  that  "there  are  typhoid 
infections  in  which  the  intestines  escape." 

I  have  seen  malarial  fever  begin  with  the  signs  which  Dr. 
Hunt  mentions  as  almost  pathognomonic  of  typhoid — even  to 
the  epistaxis,  a  symptom  that  I  have  cause  to  disregard  in  most 
cases.  Many  persons  go  through  a  whole  course  of  typhoid 
lever  without  tympanites,  diarrhoea,  eruption  or  iliac  tenderness. 
Then,  there  are  many  physicians  who  believe  that  typhoid  fever 
can  be  aborted.  As  to  the  duration,  we  cannot  always  be  sure 
from  the  history  on  what  day  of  the  fever  the  patient  comes 
under  our  care.  If  he  is  seen  the  fijst  time  with  a  temperature 
of  103°  or  104°,  the  attack  is  unquestionably  over  a  day  old; 
perhaps,  the  patient  has  had  fever  a  week  or  more.  Instead  of 
being  always  regular  and  typical,  the  temperature  in  typhoid, 
according  to  my  experience  and  that  of  some  others,  is  some- 
times distinctly  fluctuating  and  irregular.  In  several  cases, 
which  I  have  seen  lately,  the  highest  fever  for  many  successive 
davb  was  recorded  at  2  a.m.,  with  wide  ranges,  occasionally 
touching  normal,  during  the  day.  That  these  were  true  typhoid 
fever  was  proved  by  their  subsequent  course,  supplemented  by 
the  diazo  reaction.  In  short  the  only  essential  feature  of  typhoid 
fever  is  the  presence  of  the  bacillus  in  the  human  body  and  the 
resulting  symptoms  will  necessarily  vary  according  to  the  condi- 
*H.  M.  Biggs,  Medical  Record,  Dec.  18,  1897,  p.  894. 


CORRESPONDENCE.  93 

tions  under  which  the  germ  develops.  The  interpretation  of 
these  symptoms  by  individual  observers  constitutes  our  means 
of  clinical  diagnosis  and  involves  the  personal  equation. 

The  second  half  of  Dr.  Hunt's  paper  is  devoted  to  a  descrip- 
tion of  the  disease  termed  by  him  "gastric  fever."  This,  he 
considers,  a  distinct,  specific  disease,  forming  a  third  class  of 
continued  fevers,  differmg  clinically  from  malaria  and  typhoid. 
Herein  lies  the  bone  of  contention — the  unsettled  point  about 
which  the  Doctor  desires  my  opinion.  On  a  former  occasion,* 
after  considerable  labor  and  thought,  I  emphasized  my  belief 
in  the  following  statements:  "i.  Our  continued  fevers  are  either 
typhoid  or  malarial.  2.  The  first  step  in  their  diagnosis  is  the 
finding  or  excluding  of  the  malarial  parasite.  3.  This  can  be 
done  readily  and  satisfactorily  in  the  manner  indicated."  I  still 
adhere  to  these  as  true  to  the  best  of  my  knowledge,  though  I 
am  ready  to  be  convinced  to  the  contrary  at  any  time  by  proof 
as  strong  to  my  mind  as  that  which  led  mc  up  to  the  above  con- 
victions. This,  Dr.  Hunt  has  not  produced,  to  my  own  satis- 
faction at  least,  in  his  clinical  picture  of  "gastric  fever," — 
graphic  and  interesting  as  it  is.  He  describes  this  disease  as  a 
"non-contagious  form"  of  continued  fever,  "endemic  in  char- 
acter, marked  (in  the  majority  of  those  affected)  by  very  abrupt 
invasion,  chilliness,  rigors,  headache  of  greater  or  less  intensity, 
frequently  great  nausea  and  in  some  cases  vomiting."  The 
associated  symptoms  are  jaundice  (as  a  rule),  epigastric  tender- 
ness, a  peculiarly  coated  tongue,  a  very  irritable  stomach,  a 
general  soreness  over  the  abdomen,  constipation  (rarely  diar- 
rhoe),  dry,  hot  skin,  a  characteristic  "fever  odor"  and  a  consid- 
erable" thirst.  The  pulse  is  usually  slow  in  proportion  to  the 
fever,  sometimes  beating  86  to  100  per  minute  "while  the  tem- 
perature was  104°,  105°  or  106°. "  [A  very  constant  feature  in 
typhoid.]  Dr.  Hunt  regards  the  temperature  as  the  leading 
symptom  ;  "and  as  far  as  the  patient's  feelings  go,  it  constitutes 
the  disease  itself,"  which  usually  lasts,  on  an  average,  nine  days. 
This  general  summary  will  serve  to  indicate  in  a  just  manner 
what  Dr.  Hunt  calls  "gastric  fever."  It  is  far  from  my  inten- 
tion to  doubt  the  Doctor's  diagnostic  ability  or  to  question  the 
accuracy  of  his  observations,  but  it  seems  to  me,  he  has  not  in- 
*N   C.  Med.  Society,  June  1897. 


RTCVIKWS    AND    BOOK   NOTICES. 

rroduced  conclusive  evidence  to  show  that  his  cases  were  not 
either  typhoid  or  malaria.  I  have  seen  cases  of  typhoid  fever 
which  corresponded  exactly  with  his  description  of  this  so-called 
"gastric  fever."  The  initial  symptoms  given  are  often  observed 
in  true  typhoid  ;  the  general  sensation  of  soreness  in  the  abdo- 
men, without  the  presence  of  rose-spots,  the  constipation,  the 
"fever  odor,"  the  thirst,  the  slowness  of  the  pulse  compared  to 
the  temperature — all  these  i  re  common  in  typhoid.  Again,  the 
disease,  as  he  pictures  it,  certainly  presents  a  similarity  to  cases 
of  malaria  I  have  met — cases  about  which  I  would  still  have 
been  in  doubt,  but  for  the  proof  afforded  by  the  microscope. 
Those  who  wish  to  study  more  freely  the  affection  described  by 
Dr.  Hunt  I  would  refer  to  his  valuable  paper,  mentioned  in  the 
beginning  of  this  communication.  I  have  endeavored  for  the 
present  purposes  to  give  the  gist  of  it. 

From  the  testimony,  I  do  not  believe  there  is  any  specific 
"gastric  fever"  nor  dn  I  think  Dr.  Hunt  can  maintain  that  it 
constitutes  a  distinct  continued  fever.  There  is  some  authority 
t  )  sustain  me  in  this.  Osier,  in  his  "Practice  of  Medicine," 
ist  edition,  p.  348,  says:  "Many  practitioners  still  adhere  to 
the  belief  that  there  is  a  form  of  gastric  fever,  but  the  evidence 
of  its  existence  is,  by  no  means,  satisfactory  and  certainly  a 
great  majority  of  all  cases  in  this  country  are  examples  of  mild 
typhoid." 

Finally,  I  wish  to  assure  Dr.  Hunt  of  my  very  great  appreci- 
ation of  his  kindness  in  bringing  the  matter  to  my  attention. 
I  take  pleasure  in  complying  with  his  request  for  my  views 
through  the  pages  of  this  Journal.  It  is  only  aR  opinion  I 
have  expressed  here,  for  what  little  it  may  be  worth.  Dr. 
Hunt's  recorded  observations  are  all  but  perfect  in  detail  and 
his  attitude  toward  the  subject  is,  indeed,  worthy  of  commenda- 
tion. Very  truly  yours, 
Raleigh,  N.  C,  Jan.  1S9S.          HUBERT  A.  ROYSTER,M.D. 


TReviews  anb  '£00^  IRotlcee. 


Health  of  Body  and  Mind — some  Pratical  Suggestions  of  how  to 
Improve  Both  by  Physical  and  Mental  Culture.  An  extended  series  of  move- 
ments and  passive  movements  of  the  muscles.     How  the  Thought  Force  can 


REVIEWS  AND  BOOK  NOTICES.  ne 

be  directed  to  the  part,  function,  or  muscle  to  be  developed.  Good  Health  and 
Long  Life.  By  T.  W.  Topham,  M.  D.  Brooklyn  Borough,  New  York  Ciiy. 
The  author  starts  out  with  the  theory  that  physical  culture  is 
the  one  thins:  needed  to  make  the  human  race  healthy  and  wise; 
■  but  while  the  muscles  form  a  very  important  part  of  the  physi 
cal  man,  the  controlling  force,  which  comes  from  the  source  of 
all  life,  can  also  be  cultivated  for  our  benefit.  The  author  goes 
on  to  show  that  disease  is  the  infringement  of  some  law  of 
nature,  that  for  each  violation  there  is  some  punishment,  and 
that  the  penalty  fits  the  crime.  For  each  chapter  he  has  pre- 
pared a  moral  which  is  printed  at  the  bottom  of  each  page,  thus, 
under  the  chapter  on  how  to  get  well,  he  has  selected  from  Lord 
Palmerston  the  passage  "Clean  your  streets,  and  call  upon  God 
for  help"  under  "Muscle",  we  find  "Strength  Brings  Courage", 
under  "Development  of  the  Muscle",  "Symmetry  is  Beauty", 
etc.  The  various  movements  recommended  are  fully  described 
and  illustrated  by  photographs.  The  author  desires  to  impress 
upon  the  reader  the  idea  that  thought  is  a  substance,  a  some- 
thing that  has  an  influence  of  itself;  that  a  thought  can  be  felt 
if  sent  by  a  strong  will ;  that  the  thought  can  make  ourselves  or 
others  happy  or  unhappy  of  itself,  without  outward  expression. 
He  claims  that  thought  can  be  controlled  by  a  constant  and  en- 
during effort  of  the  will,  and  that  then  shall  the  affairs  of  earth 
take  on  a  more  sublimely  beautiful  aspect,  and  the  individual 
be  made  happy  in  the  knowledge  that  the  best  of  earth's  treas- 
ures are  his — namely,  a  contented  mind. 

Spinal  Caries. — (Spondylitis  or  Pott's  Disease  of  the  spinal  Column)- 
By  Noble  Smith,  F.  R.  C.  S.,  Ed.,  F.  R.  C.  P.  Lond.,  Surgeon  to  the  City 
Orthopoedic  Hospital;  Surgeon  to  All  Saints  Children's  Hospital;  Orthopaedic 
Surgeon  to  the  British  Home  for  Incurables.  Second  Edition.  Octavo,  Cloth 
153  pages.     Price  Five  shillings.     Smith,  Elder  &  Co.,  London.  1897. 

We  have  here  a  very  practical  and  interesting  study  of  spinal 
caries.  After  a  general  description  of  the  disease,  the  author 
takes  up  the  symptoms  and  diagnosis.  These  chapters  are  very 
carefully  written,  and  very  useful  in  view  of  the  author's  ex- 
perience. Especial  attention  is  given  to  the  consideration  of 
other  diseases  of  the  spinal  column  which  may  simulate  caries, 
and  to  obscure  cases.  The  chief  part  of  the  volume,  however, 
is  devoted  to  a  discussion  of  the  treatment.      The  chief  items  of 


g  REVIEWS    AND  BOOK   NOTICES. 

as  pointed  out  by  Dr.  Smith  are:  (i)  Mechanical  fixation  of  the 
spinal  column;  (2)  Adjustment  of  mechanicl  apparatus,  in  ac- 
cordance with  the  progress  toward  resolution ;  (3)  General  rest 
of  the  patient;  (4)  Modifications  of  the  bodily  movements  in  ac- 
cordance with  the  severity  of  the  case;  (5)  Nursing;  (6)  Cloth- 
ing; (7)  Food  and  medicine;  (8)  Treatment  of  complications. 
In  the  application  of  fixation  the  author  emphasises  the  impor- 
tance of  controlling  the  spine  as  far  as  possible  below  and  above 
the  seat  of  inflammation.  When  the  disease  exists  below  the 
third  or  fourth  dorsal  vertebra,the  spine  may  be  supported  suffi- 
ciently by  an  apparatus  which  extends  from  the  extremity  of  the 
sacrum  below,  to  the  level  of  the  shoulders  above;  but  if  the 
disease  is  above  this  part,  it  is  generally  and  almost  always  nec- 
essary to  continue  the  apparatus  to  the  head.  For  the  fixation 
of  the  head,  the  author  describes  a  head  band  which  is  attached 
to  the  spinal  brace,  and  while  it  fixes  the  head  allows  slight 
changes  to  be  made  by  the  surgeon  without  disturbance  of  the 
diseased  part.  Numerous  cases  are  cited  and  illustrated  by 
drawings  taken  from  life  and  museum  specimens  to  show  the 
results  of  treatment  by  the  author's  apparatus.  A  short  refer- 
ence is  made  to  Calot,s  treatment  by  forced  extension  under  an- 
eesthesia.  He  thinks  that  there  must  be  considerable  doubt 
about  the  refornoation  of  bone  in  sufficient  quantity  to  fill  the 
space  left  by  reduction  in  six  months  as  claimed  by  Calot.  That 
the  bone  does  reform, however,he  proves  byone  of  thecases  cited 
in  his  own  series.  The  specimen  and  history  of  this  case  show 
the  following  facts: 

1.  That  a  very  large  gap  may  occur  from  dissolution  of  several 
vertebrae  without  their  usual  spontaneous  coalescence,  the  spinal 
cord  being  left  exposed  in  the  thorax  and  abdomen,  unprotected 
by  a  bony  covering. 

2.  That  repair  may  take  place  while  the  undestroyed  vertebrae 
remain  separate  from  one  another. 

3.  That  repair  of  this  kind  can  progress  in  spite  of  the  most 
adverse  circumstances  in  respect  to  the  general  health  of  the 
patient. 

4.  That  in  such  a  severe  case  the  new  bony  growth  requires 
a  much  longer  time  to  become  thoroughly  solid  than  in  ordinary 
cases. 


THEEAPEUTIC  HINTS.  gy 

Literary  Notes. — Klemper's  Clinical Diagnois^by  Dr.  G.  Klem- 
perer,  Professor  at  the  University  of  Berlin  ;  first  American  from 
the  seventh  and  last  German  edition;  authorized  translation  bv 
Nathan  E.  Brill,  A.  M.,  M.  D.,  Adjunct  Attending  Physician, 
Mt.  Sinai  Hospital,  and  Samuel  M.  Brickner,  A.  M.,  M.  D., 
Assistant  Gynaecologist,  Mt.  Sinai  Hospital  Dispensary,  is  an- 
nounced for  early  publication  by  the  Macmillan  Company. 

Messers.  E.  B. Treat  &  Co.,  announces  as  nearly  ready  the  sixteenth 
edition  of  the  International  Medical  Annual. 

Besides  the  usual  summaries  of  the  year's  work,  this  edition 
will  contain  several  special  articles  of  great  merit,  among  them 
"The  Chief  Pathogenic  Batcena  in  the  Human  Subject."  "The 
Obliteration  of  the  deformity  in  Pott's  Disease";  and  Congental 
Dislocation  of  the  Hip."  It  will  be  freely  illustrated  and  the 
price  will  be  $3  00 


Ilbcrapeutic  Ibluts. 


Urticaria: 

Dr.  Bernard  Wolff,  {Jour.  Am.  Med.  Aiso.)  reports  excellent 
results  from  the  use  of  sodium  phosphate  in  this  trouble.  Dram 
doses  of  the  saturated  solution  every  three  hours,  in  acute  cases, 
and  the  same  dose  after  meals  in  chronic  cases,  gives  prompt 
relief  to  the  symptoms.  In  chronic  cases  it  needs  to  be  long 
continued  to  effect  a  permanent  cure. 

Alcohol  Instead  of  Whiskey: 

Davis,  {Jour.  Am.  Med  Asso.)  proposes  the  substitution  of 
alcohol  properly  diluted  instead  of  the  fermented  and  distilled 
liquors,  where  such  a  stimulant  is  indicated.  In  this  way  the 
physician  can  know  the  exact  amount  of  alcohol  the  patient  re- 
ceives, and  escape  the  various  harmful  substances  contained  in 
brandy,  whiskey,  wine,  beer,  etc.  He  recommends  diluted 
alcohol  to  be  administered  with  sugar  in  milk  or  meat-broth. 
Besides  being  more  accurate  it  would  be  more  economic  for  the 
patient. 


g  NOTKS    AND  ITEMS, 

Dr.  Rumbold,  Sr.,  says  that  the  functions  of  the  middle  ear 
muscles  are  to  select  and  amplify  such  sounds  as  the  listener 
desires  to  hear  most  distinctly;  making  it  appear  that  the  ears 
have  muscles  of  accommodation  quite  analogous  to  those  of  the 
eyes. 

Curettage: 

In  his  instructions  on  the  subject  oi  retained  placenta  and  begin- 
ing puerperal  sepsis,  Dr.  Wells  points  out  the  danger  of  using  a 
sharp  curette  for  the  removal  of  pieces  of  placental  tissue.  A 
septic  uterus  is  always  soft,  and  its  perforation  by  a  curette  an 
easy  matter.  Unless  the  operator  has  had  experience  in  the  use 
of  the  curette,  it  is  better  to  use  the  carefully  sterilized  finger 
to  remove  any  fragments  which  may  adhere  to  the  uterine  wall, 
and  follow  this  by  copious  inter-uterine  injections  of  creolin. 
When  the  os  is  not  sufficiently  dilated  to  admit  the  finger,  it 
should  be  enlarged  by  graduated  dilators  on  the  Barnes  bag. — 
Med.  Ceunsel. 

Follicular  Tonsillitis: 

Follicular  tonsillitis  is  an  acute  infectious  disease  and  should 
be  treated  as  such.  Whilst  systemic  treatment  is  of  paramount 
importance,  local  treatment  should  not  be  neglected.  Accord- 
ing to  Dr.  Gibb  each  crypt  should  be  carefully  cleansed  with  a 
strong  solution  of  hydrogen  dioxide,  after  which  applications  are 
to  be  made  to  each  with  a  solution  of  silver  nitrate,  40  or  90 
grains  to  the  fluidounce.  Involvement  of  the  pharyngeal  or  the 
lingual  tonsil  should  receive  similar  treatment. — Med.    Council. 


IRotee  anb  Items. 


Dr.  Morris  Wiener,  of  Baltimore,  who  has  recently  celebrated 
kis  eighty-eight  biuh-day,  is  still  in  active  practice. 

It  is  stated  that  the  manufacture  of  Koch's  new  tuberculin  has 
been  abandoned. 

The  following  certificate  was  furnished  in  a  damage  claim  for 
accident  rendered  to  the  London  Guarantee  and  Accident  In- 
surance Company. 


ITEMS    AND   NOTES.  pg 

"This  is  to  certify  that  Thorn  Bloomington,an  ore  trammeler, 
while  in  the  employ  of  the  Clifton  Car  Company  has  been  under 
my  care  for  the  following  injuries:  Slipped  on  rail  of  ore  track, 
sustained  a  compound  fracture  of  his  right  leg  (wooden),  and 
was  laid  up  for  repairs,  and  has  been  totally  disabled  from  his 
usual  employment  for  one  day." 

(Signed)  Lawson  Hogue,  M.  D. 

Damage  claimed  60  cents,  which  was  allowed. — Med.  Exami- 
ner. 

Took  His  own  Physic. — A  case  has  recently  been  decided  in 
the  Kansas  City  Federal  Court  sustaining  the  action  of  an  in- 
surance company  which  refused  to  pay  the  amount  for  which  a 
physician's  life  had  been  insured  because  he  died  by  taking 
medicine  that  he  himself  had  compounded.  He  prepared,  as 
he  thought  a  mixture  of  magnesium  citrate,  and  on  the  patient 
refusing  to  take  it,  took  it  himself  and  soon  died.  He  had  in- 
advertently used  potassium  cyanide. 

The  Ifiternational  Journal  of  Surgery  has  commenced  the 
publication  of  a  series  of  interesting  articles  on  gynecological 
subjects,  by  Dr.   Augustin  H.  Goelet,  of  New  York. 

We  are  pleased  to  announce,  that  with  this  issue  we  begin 
the  publication  of  a  series  of  instructive  papers  on  "Malaria," 
by  Dr.  J.  G.  Van  Marter,  Jr.  of  Savannah,  Ga.  Dr.  Van  Marter 
being  located  in  what  might  be  called  the  home  of  malaria  in 
this  country,  and  having  had  experience  in  Italy,  is  well  pre- 
pared to  write  on  the  subject.  The  articles  will  appear  from 
time  to  time  during  the  year. 

*'Nit" — According  to  a  correspondent  of  the  Boston  Medical 
and  Surgical  Journal  xXic.  examination  of  the  heads  of  756  child- 
ren in  one  of  the  Boston  Grammar  schools  revealed  the  following 
condition : 

200  (26  per  cent.)  had  no  nits. 

234  (31  per  cent.)  had  a  few  nits. 

269  (35-5  per  cent.)  had  a  considerable  number  of  nits. 

53  (7  per  cent.)  had  a  very  large  number  of  nits. 

These  children  received  cards  informing  their  parents  of  the 
condition  of  the  children's  heads.     Two  weeks  latter  an  exami- 


,  QQ  NECROLOGY. 

nation  of  609  of  them  showed  only  23  free  from  nits.  The  writer 
says  that  the  great  majority  of  these  children  came  from  respect- 
able families.  The  very  remarkable  fact  appeared  that  the  best 
record  for  freedom  from  pediculosis  was  held  by  the  colored 
children,  and  the  writer  attributed  this  fact  to  the  oils  or  poma- 
des applied  to  the  hair  by  this  class  to  make  it  lay  smooth. 

Dr.  Robert  Duval  Jones,  of  Newbern,  was  married  December 
29th  to  Miss  Kate  Walker,  of  Wilmington. 

Artificial  Oysteks. — There  is  no  further  excuse  for  the  india- 
rubber  oyster  being  used  in  the  soup  at  church  festivals.  Arti- 
ficial oysters  on  the  half- shell  are  the  latest  innovation  in  Paris. 
It  has  not  been  determined  what  are  the  constituents  of  these 
delicacies,  but  they  are  said  to  be  harmful.  The  shells  only  are 
genuine  the  oyster  being  fastened  in  by  means  of  a  tasteless 
paste.  They  are  sold  at  twenty  cents  a  dozen,  and  when  eaten 
with  vinegar  cannot  be  distinguished  from  the  real  oyster. 


NECROLOGY. 


Dr.  J.  S.  Murphy,  at  Burlington,  N.  C.  December,    20,  1897. 

Dr.  Joseph  O'Dwyer,  aged  56  years,  at  New  York,  January  7, 
1898.  Dr.  O'Dwyer  was  the  inventor  of  intubation  and  he 
could  have  no  greater  monument. 

Dr.  Lewis  Crusius,  aged  40  years,  at  St.  Louis,  January  2, 
1S68.  Dr.  Crusius  is  well  known  to  every  physician  in  the 
country  as  the  author  of  theartistics  drawings  on  the  Atikammia 
Calendars.  He  was  connected  with  the  Medical  Fortnightly  and 
for  several  years  held  the  chair  of  histology  in  the  Marion  Sims 
College  of  Medicine. 

Mr.  Ernest  Hart,  editor  of  the  British  Medical  Journal,  in 
London,  January  7,  1898.  A  note  was  made  in  the  journal 
several  weeks  since  that  Mr.  Hart  was  a  vie  im  of  diabetes,  and 
that  necrosis  of  the  bones  of  his  foot  necessitated  amputation. 
His  health  has  steadily  failed  since  that  time. 


SYR.  HYPOPHOS.  CO.,  FELLOWS 

OftntainS  the  Essential   Elementg  of  the  Anlmal  organization— Potash  and  Lime; 
Agents — Iron  and  Maganese: 


The  Tonics Quinine  and  Strychnine; 

And  the  Vitalizing  Constituent — Phosphorus;  the  wholecomMned  in  the  form  of  a  Syrup  with- 

Sligbtly  Alkaline  Reaction- 
It  Differs  in  Its  Effects  from  all  Analo^ons  Preparations;  and  it  possesses  the  important  properties 

of  being  pleasant  to  the  taste,  easily  borne  by  the  stomach,  and  harmless  under  pro 
longed.  Hse. 
ft  has   Gained  a  Wide   Reputation,  particularly  in  the  treatment  of  Pulmonary  Tuberculosis, 

Chronic  Bronchitis,   and  other  affections  of  the  respiratory  orgons.     It  has  also 

been  employed  with  much  success  in  various  nervous  and  debilitating  diseases. 
Ill  Curati?e  Power   is  largely  attributable '  )  Its  stimulant,  tonic,  and  nutritive  properties, 

by  means  of  which  the  energy  of  the  system  is  recruited. 
Its  Action  is  Promptl  it  stimulates  the  appetite  and  the  digestion,  it  promotes  assimilalion, 

and  it  enters  directly  into  the  circulation  with  the  food  products. 

The  prescribed  dose  produces  a  feeling  of  buoyancy,  and  removes  depression  and  mel- 
•ncho ly ;  hence  the  preparation  is  of  great  value  in  the  treatment  of  mental  and  nervouB 
affections.  From  the  fact,  also,  that  it  exerts  a  double  tonic  influence,  and  inducei  a 
healthy  flow  of  the  secretions,  its  use  is  indicated  in  a  wide  range  of  dieeaies. 


NOTICE-CAUTION. 

The  success  of  Fellows*  Syrup  of  Hypophosphites  has  tempted  certain 
persons  to  offer  imitations  of  it  for  sale.  Mt.  Fellows,  who  has  examined 
samples  of  several  of  these,  finds  that  no  two  of  them  affe  identical^ 
and  that  all  of  them  differ  from  the  original  in  composition,  in  freedom 
from  acid  reaction,  in  susceptibility  to  the  effectg  of  oxygen  when  ex- 
posed^to  light  or  heat,  in  the  property  of  retaining  the  stryoh- 
Sine  in  solution,  and  in  the  medicinal  effect*. 

As  these  cheap  and  inefficient  substitutes  are  frequently  dispensed  in- 
itecwi  of  the  genuine  preparation,  physicians  are  earnestly  requeited, 
when  prescribing  the  Syrup,  to  write  "Syr.  Hypophoi.  Fellows." 

As  a  further  precaution,  it  is  advisable  that  the  Syrup  should  be 
ordered  in  the  original  bottles ;  the  distinguishing  marks  which  the  bot- 
tles (and  the  wrappers  surrounding  them)  bear,  can  then  be  examined, 
and  the  genuineness— or  otherwise — of  the  contents  thereby  proved. 


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©rioinal  Communications. 


DRAINAGE  AFTER  NORMAL   LABOR.* 

By  Livius  Lankford,   M.D.,  Norfolk,  Va. 


I  HAVE  always  respected  and  to  a  large  extent  been  governed 
by  the  teachings  of  my  superiors.  Time  honored  customs 
both  in  religion  and  medicine  have  ever  found  the  writer  a 
faithful  follower.  After  two  years  attendance  on  the  lectures 
of  Professors  Budd  and  Lusk,  in  which  they  urged  the  im- 
portance of  confining  the  parturient  woman  from  tsn  to  four- 
teen days  in  bed  after  delivery,  I  began  to  practice  medicine  in 
Southampton  county,  Va.  My  second  case  of  obstetrics  was  a 
woman,  (white)  whom  I  delivered _of  her  9th  child.  Of  course 
I  did  not  think  it  necessary  the  hour  I  left  her  to  give  instruc- 
tions that  she  must  not  think  of  dressing  and  remaining  up 
under  ten  days.  When  I  visited  her  on  the  third  day  I  found 
her  up,  dressed,  lap  full  of  children's  clothes  which  she  was  re- 
pairing, and  her  foot  on  the  end  of  a  woodea  rocker  of  a  little 
plank  cradle  which  she  would  kick  whenever  the  baby  fretted. 
When  I  expressed  my  surprise  at  seeing  her  up,  and  insisted 
upon  her  taking  the  bed  at  once,  she  only  laughed  and  re- 
marked, this  was  her  9th  and  she  had  always  gotten  up  on  the 
third  day  and  gone  to  work,  that  she  never  could  "endure"  the 
bed  when  she  was  not  sick.  She  informed  me  that  she  would 
?ioi  go  back  to  bed  unless  she  felt  sick,  and  she  did  not.  How- 
*Read  before  the  Tide  Water  Medical  Association,  January  20,  1898. 


JQ2  LANKFORD.— DRAINAGE  AFTER  NORMAL  LABOR. 

ever,  I  visited  her  daily  for  a  week,  at  the  expiration  of  which 
time  I  asked  to  examine  the  uterus.  I  recall  distinctly  how  small 
and  well  contracted  it  was. 

Eighteen  years  ago  a  large  per  cent,  of  the  women,  in  the 
rural  districts  of  eastern  Virginia  at  least,  were  attended  by 
midwives  in  normal  labors.  From  my  first  case  I  began  to 
administer  chloroform  during  the  second  stage  of  labor.  I 
soon  learned  that  I  was  the  only  physician  in  all  that  sec- 
tion who  gave  chloroform  in  every  case  of  labor.  This  gave 
me  quite  a  reputation  among  primiparas,  as  well  as  those 
multiparas  who  had  suffered  intensely  in  previous  labors, 
(and  I  remember  how  severely  censured  I  was  by  the  old  M.  D.  's 
for  giving  chloroform  in  every  case).  So  it  was  not  many  years 
before  I  had  attended  a  great  number  of  multiparas  and  I 
learned  from  them  that  a  majority  left  the  bed  on  the  third  day. 
I  naturally  become  much  interested  in  these  third  day  women 
and  when  I  would  sometimes  be  called  to  their  homes  a  month 
or  two  subsequent  to  their  deliveries  to  visit  other  members  of 
the  family  I  asked  permission  to  examine  the  uterus.  Some  ob- 
jected, but  others  consented,  and  not  once  do  I  recall  finding 
a  subinvoluted  or  much  prolapsed  uterus.  Nearly  all  of  them 
were  hard  working  truckers'  and  farmers'  wives.  These  facts 
were  directly  in  opposition  to  my  college  and  text  book  teach- 
ings, and  opened  up  a  new  line  of  thought  for  me.  Of  course 
from  boyhood  I  had  read  how  the  Indian  squaws  and  other 
savage  women  would  be  delivered,  and  in  few  hours  up  and 
going,  how  the  negro  women  of  the  South  would  plough  and 
hoe  all  day,  be  confined  that  night,  next  day  up  and  at  the 
spinning  wheel.  For  ten  }ears  I  saw  how  easily  those  country 
women  got  up  from  their  parturitions.  During  my  stay  there 
I  attended  alone  and  in  consultation  with  other  doctors  about  700 
women  in  confinement  with  only  one  death,  puerperal  eclampsia. 
I  saw  her  in  consultation  just  before  death.  My  invariable 
practice  these  ten  years  as  it  has  been  since,  was  to  keep  the 
woman  in  bed  until  the  loth  day  if  I  could,  and  give  her  30  M. 
ergot  three  times  per  day  during  that  time.  When  I  moved  to 
Norfolk  I  soon  found  that  my  lying-in  women  were  not  doing 
so  well  as  those  in  the  country.  I  experienced  no  difficulty  in 
keeping  them  in  bed  10  days,  they  often  not  feeling  like  getting 
up  on  the  loth  day.      At  the  expiration  of  the   first   and  second 


LA;jrKFORD.— DRAINAGE  AFTER  KORMAL  LABOR.  ,03 

Tnonth  these  who  did  poorly  would  ^ive  all  the  symptoms  of 
subinvolution.  It  did  not  take  long  to  prove  from  a  digital 
examination  and  the  sound  that  about  one-twelfth  of  my  par- 
turient women  were  left  with  a  subinvoluted  uterus,  which  I 
had  to  treat  at  once.  I  would  call  attention  to  the  important 
fact  that  a  very  large  per  cent,  of  my  obstetrical  practice  then 
was  among  the  poorer  classes  of  the  city,  where  it  was  impossi- 
ble to  have  trained  nursing,  or  even  any  nurse  at  all  except 
what  an  older  child  could  render.  I  beg  pardon  for  being  so 
long  in  arriving  at  the  gist  of  this  paprr.  Whatever  will  hasten 
the  return  of  the  uterus  to  its  normal  weight  and  condition  after 
gestation  is  what  we  mo<;t  need  in  obstetrical  practice.  My  ex- 
perience during  eighteen  years  and  the  experiment  with  the 
25  cases  which  I  will  report  in  this  paper  leads  me  to  believe 
that  thorough  drainage  for  the  two  weeks  following  gestation 
will  do  this.  For  a  moment  let  us  glance  at  the  processes  by 
means  of  which  the  uterus  returns  to  its  non-puerperal  condi- 
tion, or  '■''involution'  as  it  is  called. 

M.  Sanger  in  Annals  of  Gynecology  of  Boston,  July  1888, 
proved  the  first  factor  in  involution,  was  uterine  contraction 
just  after  delivery,  at  which  time  constant  compression  of  the 
nutrient  vessels  diminished  the  supply  of  reparative  material  to 
that  extent  that  fatty  degeneration  of  the  protoplasm  of  the 
giant  muscular  cells  was  produced. 

The  next  important  factor  is  the  exudation  through  the  uterine 
sinuses  and  other  smaller  vessels  from  the  body  of  uterus  by 
way  of  the  wounded,  or  placental  surface,  out  into  uterine 
cavity  and  vagina,  which  is  the  "lochia."  Now  comes  the  key 
to  my  little  paper  if  there  be  one.  That  which  will  forestall  the 
evils  incident  to  lochial  stagnation  in  uterus  and  vagina  is 
most  imperative.  The  first  evil  I  believe  to  be  septic  absorp- 
tion, and  second  leaving  the  gravid  uterus  subinvoluted.  As 
stated  before  I  believe  thorough  drainage  to  a  large  extent  will 
prevent  these  evils.  Now  what  is  the  safest,  and  most  practi- 
cal way  to  secure  this  drainage,  thereby  ridding  the  vagina  of 
a  variety  of  micro-organism,  such  the  as  the  diplo  and  strepto- 
cocci, rod  bacteria  and  occasionally  gonococci.  Of  course  they 
vary  in  quantity,  but  many  of  the  best  writers  claim  that  they 
increase  in  abundance  with  the  advance  of  the  first  week.  We 
will  look  at  the  cases  experimented  on  for  an    answer. 


JQ4  LANKrOED.-DKAINAGE  AFTER  NOEMAL  LABOR. 

During  the  first  part  of  1S65  I  was  greatly  annoyed  by  having 
under  treatment  several  obstinate  cases  of  subinvolution.  From 
what  I  had  experienced  in  my  earlier  years  of  practice  in  observ- 
ing those  women  who  would  leave  their  bed  on  third  day  and 
how  free  they  were  from  puerperal  troubles,  I  determined  to 
conduct  a  group  of  cases  at  their  confinements  in  the  following 
way,  being  careful  to  select  only  strong,  healthy  women  for  the 
experiment:  My  first  case  was  Mrs.  M.  age  19  years,  pri- 
mipara.  She  was  confined  May  20,  '95.  Was  about  ten 
hours  in  labor,  which  was  normal  in  every  way.  Just  forty- 
eight  hours  after  delivery  in  my  presence  I  had  her  taken 
up  and  comfortably  seated  in  a  rocking  chair.  Her  first  re- 
mark was  I  feel  quite  a  flow.  I  examined  same  at  once  and 
found  it  only  a  pale  red  lochia.  She  remained  in  chair  just  one- 
half  hour  when  she  was  put  to  bed  saying  she  felt  all  right.  I 
gave  instructions  to  let  her  remain  in  bed  two  hours  then 
take  her  up  for  half  hour  and  so  on  until  bed  time.  The  next 
morning  I  called,  found  condition  splendid,  ordered  her  to  sit 
up  one  hour  in  every  three,  of  course  the  other  two  in  bed. 
This  was  kept  up  until  the  fifth  day  when  I  allowed  her  to  sit 
up  two  hours  and  recline  two.  On  the  loth  day  I  examined 
the  uterus  carefully.  Involution  was  advancing  rapidly,  am 
sure  uterus  could  not  have  weighed  more  than  a  pound.  The 
cervix  was  well  contracted,  so  much  so,  that  with  difficulty  the 
finger  could  be  forced  up  to  the  os  internum  where  the  ring  was 
firm  and  resisting.  This  woman  will  assure  any  one  that  her 
health  was  perfect  after  this,  and  is  now.  She  gave  birth  to 
her  second  child  last  April,  I  was  not  as  systematic  in  her  getting 
up  this  time  as  at  first,  for  I  had  before  this  completed  my  25th 
case  conducted  in  this  way,  but  she  observed  the  first  rules 
quite  closely.  The  second  case  was  Mrs.  C.  living  4  miles  in 
country,  who  was  delivered  May  28th  of  her  nth  full  term  child. 
The  labor  was  normal,  in  forty-eight  hours  she  was  permitted 
to  sit  up  one  hour  instead  of  half  hour  as  in  first  case  then  put 
to  bed  for  two  hours  and  so  on  until  fifth  day,  when  she  sat  up 
half  of  the  time  until  the  loth.  I  examined  her,  and  while  I 
could  not  expect  to  find  her  uterus  as  small  as  the  primipara, 
yet  it  was  well  contracted  and  her  general  condition  perfect. 
She  is  a  very  hard   worker    with    large    family.      March    i,    '97, 


LAKKFOED.— DRAINAGE  AFTER  NORMAL  LABOR.  jqc 

1  attended  her  when  she  gave  birth  to  her  12th  living  child. 
Her  health  is  excellent  now.  It  would  consume  too  much  of 
your  time  and  not  be  profitable  to  report  all  of  the  twenty-five 
•cases.  I  have  a  careful  record  of  every  case,  and  without  an  ex- 
ception they  recovered  and  are  in  good  health  to-day  as  far  as  I 
know.  Nine  of  them  have  given  birth  the  second  time  and  one 
on  December  23rd,  the  third  birth — an  Italian  woman. 

Next  which  is  an  important  question.  What  are  the  dangers,  if 
any,  to  the  woman  who  sits  up  one-third  of  the  day  forty-eight 
hours  after  the  labor?  From  all  the  literature  which  I  had  on 
post-partum  haemorrhage  I  satisfied  myself  that  the  danger  from 
this  cause  forty-eight  hours  after  delivery  was  m7.  As  to  puerperal 
hoemorrhage  so  called,  I  suppose  there  is  more  danger.  This 
form  of  haemorrhage,  which  may  be  expected  any  time  from  the 
third  to  seventh  day  is  not  considered  dangerous,  being  caused 
from  the  separation  of  the  thrombi  at  the  placental  site.  Should 
it  appear  during  the  hour  which  the  patient  is  sitting  up,  she 
would  at  once  go  to  bed,  the  doctor  be  summoned  and  the  usual 
methods  be  resorted  to  for  controlling  it.  I  have  seen  only 
three  cases  and  they  were  readily  checked  without  return. 
The  next  danger  might  be  displacements.  Dr.  Thornton,  in  a 
paper  read  before  the  British  Gynaecological  Society  of  London, 
in  i889,on  Uterine  Displacements, claimed  that  by  far  the  largest 
number  of  displacements  were  either  retroversions  or  retroflex- 
ions and  that  he  believed  subinvolution  was  principally  the 
cause  of  these  displacements,  and  I  have  attempted  to  prove 
that  il  we  give  the  uterus  thorough  drainage  subinvolution  will 
be  exceedingly  rare.  I  have  fosnd  it  simply  impossible  to 
enforce  thorough  cleanliness  of  the  bed  clothing  of  the  poorer 
classes  in  my  practice.  They  have  not  sufficient  clothing  for 
themselves  or  their  beds.  Therefore  when  they  are  confined 
constantly  to  the  bed  the  conditions  become  peculiarly  favora- 
ble to  the  development  of  the  mentioned  micro-organisms  some 
of  which  are  often  present  in  the  vagina  previous  to  confine- 
ment, and  others  can  obtain  entrance  through  the  vulva.  With 
such  patients  it  would  be  exceedingly  risky  to  advis.^  them  to 
use  the  douche.  So  there  is  no  way  in  my  judgment,  better  to 
secure  drainage  of  the  vagina  than  to  get  them  up  as  early  as  the 
third  day  for  at  least  one-third  of  the  time.      I   have  the  gicat 


Io6       MYERS. -nYPERTKOPHY  OF  THE  PHARYNGEAL  TONSIL. 

army  of  the  savage  tribes  and  the  Southern  negress  to  sustain 
me  in  proving  this  to  be  not  so  great  an  evil  as  confinement  in 
a  filthy  bed,  or  even  a  clean  bed  if  you  please,  yet  with  the 
vagina  constantly  filled  with  a  septic  lochia. 


HYPERTROPHY  OF  THE  PHARYNGEAL  TONSIL  OR 
ADENOIDS  OF  THE  NASO-PHARYNX.* 

By  Harry  L.  Myers,  M.  D.,  Norfolk,  Va. 


IT  is  not  without  hesitation  that  I  re-introduce  to  you  the  sub- 
ject of  adenoids  or  hypertrophy  of  the  pharyngeal  tonsil.  I 
am  well  aware  that  more  has  been  written  about  this  subject 
than  any  other  perhaps  on  the  list  of  medical  specialties,  and 
that  it  has  been  thoroughly  considered  from  every  standpoint, 
nevertheless,  the  trouble  is  so  wide-spread,  the  danger  of  neg- 
lected cases  so  great  and  the  treatment,  if  taken  in  time  and 
properly  conducted,  productive  of  so  much  good  that  I  am  en- 
couraged to  give  expression  to  a  few  thoughts  on  the  subject. 

The  pharyngeal  tonsil,  in  its  normal  state,  is  a  small  bunch  of 
lymphoid  tissue  lying  in  the  upper  back  part  of  the  pharyngeal 
vault,  about  on  a  level  and  extending  between  the  orifices  of  the 
eustachian  tubes.  Its  structure  is  identical  with  that  of  the 
faucial  tonsils,  being  composed  chiefly  of  lymph  tissue.  The 
hypertrophy  of  this  tissue  is  a  disease  of  childhood,  arising 
usually  during  infancy  and  extending  generally  to  puberty, 
when,  like  other  glandular  enlargements,  they  are  prone  to  dis- 
appear. This  rule,  however,  has  numerous  exceptions,  and  the 
disease  is  often  encountered  in  persons  long  past  the  age  of 
puberty.  In  my  own  experience  it  has  seemed  to  give  more 
trouble  between  the  ages  of  five  and  twelve  than  in  earlier  or 
later  years,  though  I  have  removed  the  growths  from  patients 
long  past  the  age  of  thirty  years. 

Leaving  out  the  microscopical  appearances,  we  will  spend  the 
remainder  of  the  time  allotted  to  this  paper  discussing  the  more 
*Read  before  the  Tide  Water  Medical  Association,  January  20,  1898. 


MTERS.-HYPERTROPHY  OF  THE  PHARYNGEAL  TONSIL.  joy 

practical  points  of  etiology,  symptoms,  appearances,  results  of 
neglected  treatment, with  a  short  mention  of  diagnosis  and  treat- 
ment. 

Undoubtly  the  strongest  factor  in  the  etiology  of  this  trouble 
is  that  peculiar  diathesis  which  we  find  in  so  many  children, 
known  as  lymphatism — a  condition  almost  synonamous  with 
scrofula,  or,  to  be  conservative,  we  may  say  that  it  is  the  con- 
dition but  one  step  removed  from  this  diathesis.  Accompanying 
the  hyperplasia  of  this  tissue  will  be  found  in  most  cases  en- 
largement of  the  faucial  tonsils  and  the  glands  along  the  sides 
and  back  of  the  pharynx, together  with  a  hypertrophic  condition 
of  the  tissues,  covering  the  turbinated  bodies  of  the  nose.  In- 
deed, there  will  be  found  an  over-activity  in  all  the  glandular 
structures  constituting  the  condition  before  mentioned,lympha- 
tism. 

According  to  Bosworth,  eruptic  fevers  and  heredity  may  also 
be  mentioned  as  etiological  factors. 

In  subjects  of  lymphatic  temperament,  the  pharyngeal  tonsil, 
situated,  as  it  is,  midway  between  the  most   sensitive  tissues  of 
the  upper  air  tract,  is  affected  by  every   pathological   condition 
occurring  in  these  parts:  every  cold  lights  afresh  the  inflamma- 
tory   conditions  and  results   in   additional  hypertrophy  of    the 
lymphoid  structure,  until,  in  the  worst  cases,  almost  the   entire 
space  of  thevault  from  the  alas  of  the  vomer  down  to  the  oro-phar- 
ynx,  and  from  the  orifice  of  one   Eustachian  tube    to     the  other 
will  be  filled  with  the  growths.       In  many  cases  the  growths, 
after  the  manner  of  hypertrophied  glandular  tissue,hangs  down 
in  bunches,covering  theorifice  of  the  Eustachian  tubes  and  often 
almost  filling   the  posterior  nares.       There  is  still  another  form 
in    which    the   connective  tissue    elements     are   more    marked 
which  case   the    growth   is   more   sessile    and  more  closely    re- 
sembles the  hypertrophied  faucial  tonsil.      This  form,  while  giv- 
ing rise  to  much  trouble,  does  not  result  in  as  much  damage  as 
the  pendulous  and  more  obstructive  form.       These  inflamed  se- 
creting vegetations  lying  in  the    centre  of  the  already  limited 
space  of  the  upper  air  tract  of  the  child,  partially  or  almost  en- 
tirely filling  the  posterior  nares  and  the  naso-pharynx  with  their 
turgid  forms,  covered  with  a  thick,  viscid   and   tenacious  secre- 
tion, present  to  us  the  first  and  most  characteristic  symptom  of 
the  trouble,  mouth  breathing.      This  symptom  is  ever  present  in 


joS  MYERS.— nVPEIlTROPIIY  OF  THE  PHARYNGEAL  TONSILS. 

bad  cases,  and  while  in  n:ild  cases  it  may  not  be  so  noticeable  irr 
the  day-time,  when  the  upright  position  of  the  child  lessens  the 
turgescence  of  the  growth  and  allows  him  to  partially  breathe 
through  the  nose,  it  will  almost  invariably  be  present  when  the 
child  is  asleep.  During  this  period  another  important  symptom 
frequently  arises,  nightmare,  the  child  jumping  up  and  crying 
out  in  the  sleep,  due  to  improper  aeration  of  the  blood  as  a  result 
of  the  obstructed  respiration.  The  stertorous,  noisy  breathiug 
of  children  during  sleep  is  also  due  to  this  cause,  from  the  re- 
laxation of  the  palate.  When  there  is  much  stertor,  the  faucial 
tonsils  will  also  be  found  enlarged  in  most  cases.  Another  symp- 
tom much  complained  of  is  the  excessive  discharge  of  secretion 
of  a  muco-purulent  variety,  and  while  the  bulk  of  this  usually 
flows  down  the  throat,  a  part  forces  itself  through  the  nostrils, 
and  often,  on  account  of  its  acrid  character,,  causes  excoriation 
of  the  anterior  nares  and  upper  lip.  Indeed,  when  I  see  an  ex- 
coriated nose  and  lip  in  a  child,  I  feel  sure  that  it  is  the  subject 
of  adenoids,  which  is  accompanied  by  an  acute  or  chronic  rhinitis. 
The  interference  with  proper  phonation  is  a  characteristic  symp- 
tom. The  patient  talks  as  if  the  nostrils  and  mouth  were  filled^ 
it  is  the  voice  of  a  cold  in  the  head:  ^*m"  and  "n"  become  "eb"' 
and  "ed'',as  well  described  by  Bosworth  due  to  the  interruption 
of  the  sound  waves  in  the  upper  air  passages  which  constitute 
the  sounding  board  of  the  voice. 

Hearing  is  affected  in  varying  degrees,  from  slight  dulness  to 
distressing  deafness,  as  a  result  of  either  mechanical  obstruction 
rarefaction  of  the  air  in  the  aural  cavities  by  interference  with 
respiration,  direct  extension  of  inflammation  along  the  tubes  or 
direct  interference  by  pressure  to  the  return  current  of  blood 
from  the  ears,  causing  congestion.  I  repeat,  any  one,  or  a  com- 
bination of  any  or  all  of  these  factors,  would  readily  explain  the 
symptoms  of  the  varying  degrees  of  deafness. 

The  scope  of  this  paper  does  not  permit  my  going  into  the 
whole  symptomatology  of  this  affection,  but  I  have  mentioned 
the  most  prominent  symptoms,  and  so  characteristic  are  they 
that,takcn  in  connection  with  the  general  expression  of  the  face, 
the  diagnosis  should  be  simple  almost  before  an  examination  is 
made.  It  should  be  noted,  however,  that  in  ihe  milder  cases 
but  one  or  more  of  these  symptoms  may  be  prominent,  while 
other  symptoms  may  be  present  in   but  slight  degree  or  not  at 


MYERS— HYPERTROPHY  OF  THE  PHARYNGEAL  TONSILS.  j  qq 

all,  hence  no  diagnosis  would  be  complete  without  a  careful  ex- 
amination of  the  passages,  of  which  I  shall  speak  later  on.  Un- 
der differential  diagnosis  I  think  I  hardly  need  mention  but  one 
disease,  that  of  retro-pharyngeal  abscess.  I  knew  of  one  case 
in  which  the  child  having  adenoids  wa.s  successfully  operated  on 
for  this  trouble  without  relief  of  the  trouble  to  respiration.  He 
was  taken  to  another  physician,  who  discovered  the  abscess  and 
incised  it,  with  entire  relief  of  symptoms.  As  this  complication 
might  easily  escape  the  eye  of  even  an  expert,  it  seems  to  be 
worthy  of  mention  in  this  category.  To  attempt  to  deal  minutely 
with  the  results  of  neglected  treatment  of  adenoid  vegetations 
would  be  impossible  in  a  paper  of  this  nature, hence  I  shall  deal 
very  briefly  with  this  division. 

The  most  serious  results  of  adenoids  are  to  be  found  in  the 
ear.  Meyer,  in  his  paper  on  "Adenoid  G.owths  in  the  Naso- 
pharyngeal Space, "ireports  that  out  of  a  series  of  175  cases  of 
adenoids,  130  suffered  with  ear  trouble.  Killion,  another  au- 
thority, estimates  that  7^^  of  ear  troubles  in  childhood  are  the 
result  of  adenoids.  These  figures  seem  large,  but  any  aurist 
will  be  able  to  confirm  them.  Let  me  advise  you,  who  are  not 
already  familiar  with  the  subject, that  every  time  you  find  a  child 
suffering  with  an  earache  you  make  an  examination  foradenoids 
and  you  may  be  the  means  of  saving  that  child  from  deafness  or 
even  death  in  later  years. 

The  next  most  jimportan;  disease  resulting  partially  or  en- 
tirely from  adenoids  is  naso-pharyngeal  catarrh.  Bosworth  be- 
lieves that  at  least  60^  of  all  such  cases  result  from  those  vege- 
tations, and  many  authorities  would  give  a  greater  percentage. 
Another  result  of  neglect  to  treat  this  trouble  will  be  seen  in  the 
dulness  of  intellect  and  general  disturbances  of  nutrition  and 
development  of  the  child.  Many  a  child  has  labored  under  the 
disgraceful  appellation  of  the  ''school  dunce"  when  the  brightest 
intellect  lay  concealed  beneath  the  grasp  of  this  affection. 

Just  here  it  seems  to  me  to  be  well  to  naention  a  few  of  the  reflex 
effects  of  adenoids.  Chief  among  these  I  place  spasmodic  laryn- 
gitis of  childhood.  While  I  admit  that  this  disease  is  not  always 
dependent  upon  adenoids,  I  firmly  believe  that  this  habit  and 
the  asthmatic  troubles  of  childhood  can  be  in  a  great  measure, 
if  not  entirely,  cured  by  there  moval  of  the  growths  when  they 
exist.      Their  removal  seems  also  to  exert  a  curative  influence  on 


J  J  Q  MYERS.— HYPERTROPHY  OF  THE  PHARYNGEAL,  TONSILS. 

the  acute  subglottic  laryngitis  or  false  croup  of  childhood  though 
by  direct  effect  rather  than  removing  a  reflex  cause.  Nocturnal 
enuresis,  headache,  irritating  cough  and  the  habit  of  winking 
the  eyes,  much  resembling  facial  chorea,  are  also  reflexes,  fre- 
quently dependent  upon  the  growth,  though  the  headache  and 
the  irritation  arc  more  often  due  to  a  refractive  error  of  the  eyes. 

I  will  conclude  my  paper  with  a  short  description  of  exami- 
nation and  treatment.  When  a  child  is  brought  to  me  showing 
any  of  the  symptoms  above  described,  I  first  examine  the  fauces 
by  means  of  a  head  mirror,  with  reflected  light,  using  my  finger 
as  a  tongue  depressor  as  a  child  is  often  frightened  by  an  instru- 
ment. This  examination  alone  will  sometimes  reveal  portions 
of  the  growth  which  extend  below  the  arch  of  the  throat,  as  the 
child  gags.  If  the  child  is  tractable,  and  many  even  as  young 
as  five  years  are,  I  combine  with  the  head  mirror  a  small  Yz  inch 
rhinoscopic  mirror  to  examine  the  post  nasal  space,  which  im- 
mediately shows  the  extent  and  position  of  the  vegetations.  My 
next  step  is  to  introduce  a  few  drops  of  a  2^  solution  of  cocaine 
by  means  of  an  atomizer  up  each  nostril.  I  then  wait  five 
minutes  to  allow  the  drug  to  shrink  down  the  vascular  tissue  of 
the  turbinate  bodies  so  that  I  can  examine  the  nares  for  obstruc- 
tions of  any  kind.  In  many  cases  this  step  will  reveal  the 
dependent  vegetations  in  the  post  nasal  space,  vibrating  back 
and  forth  with  the  respiratory  movements.  If  the  child  is  too 
young  ©r  too  much  frightened  to  permit  either  of  these  methods 
being  carried  out,  I  insert  a  mouth  gag  between  the  teeth  and, 
either  by  force  or  partial  anesthesia,  I  insert  the  fore-finger  back 
of  the  palate  into  the  post  nosal  space  and  locate  the  growths 
by  touch.  This,  however,  is,  I  must  admit,  easier  said  than 
done,  as  it  requires  a  good  deal  of  experience  to  perform  the 
feat  in  a  struggling  child  and  an  equally  experienced  touch  to 
appreciate  the  condition  when  felt,  especially  if  the  adenoids  are 
not  very  great  in  extent. 

Having  been  satisfied  as  to  the  presence  of  the  growths,  the 
method  of  removal  is  selected  according  to  the  age  of  the  child 
and  the  form  of  the  growth. 

In  children  old  enough  to  be  reasoned  into  voluntary  submis- 
sion to  the  operation  I  am  in  the  habit  of  making  several  appli- 
cations of  a  10  per  cent,  solution  of  cocaine  on  a  post  nasal  ap- 
plicator to  the  growths.     White's  palate  retractor  is  then  placed 


MYERS.— HYPERTROPHY  OF  THE  PHARYNGEAL  TONSILS.  j  j  j 

in  position  and  the  growths  removed  according  to  their  charac- 
ter, by  means  of  forceps  designed  for  the  purpose  or  a  post  nasal 
cold  wire  snare  introduced  through  the  mouth,  guided  by  the 
rhinoscopic  mirror  and  reflected  light,  the  patient  holding  down 
the  tongue.by  means  of  a  long  handled  depressor.  This  method 
is  selcom  applicable  in  young  children.  In  operating  upon 
young  children  I  believe  an  anaesthetic  (and  I  prefer  chloroform 
administered  just  to  the  point  of  insensibility)  is  always  neces- 
sary. The  child  may  be  placed  upon  a  table,  the  head  project- 
ing over  the  end  so  as  to  keep  the  blood  from  the  throat,  and 
the  grow^ths  removed  either  piecemeal  by  forceps  or  in  a  more 
wholesome  manner  by  means  of  a  specially  constructed  curette, 
a  Gottstein  probably  being  the  besc.  It  is  not  always  possible 
to  accomplish  the  removal  of  all  the  growths  at  one  sitting,  and 
it  is  well  to  inform  the  patient  of  this  before  operating.  It  is 
always  advisable  to  allow  several  days  to  intervene  between 
operations.  In  older  children  and  adults  the  fibrous  connective 
tissue  of  the  adenoids  is  more  developed  and  in  m.y  experience 
it  is  well  to  remove  this  form  by  means  of  the  cold  snare,  as  the 
forceps  are  apt  to  do  damage  to  the  surrounding  tissues  by  at- 
tempting to  tear  away  pieces  of  the  fibrous  tissue.  The  after 
treatment  consists  of  a  few  days  quiet  indoors.  The  hemor- 
rhage is  generally  of  little  consequence. 

My  subject  would  not  be  finished  without  saying  a  few  words 
about  those  cases  which  do  not  require  operative  measures, but, 
on  account  of  the  excessive  secretion  and  consequent  discomfort 
produced,  render  mild  treatment  necessary.  These  cases  do 
well  under  the  application  three  times  weekly  of  an  astringent 
such  as  tr.  iodine  i  part;  glycerine  3  parts,  swabbed  over  the 
growth  by  means  of  a  post  nasal  applicator,  the  nasal  cavities  in 
the  meantime  being  cleansed  night  and  morning  with  an  ato- 
mizer, or  better,  by  means  of  a  small  glass  arrangement  known 
as  the  Birmingham  douche.  In  children  the  administration  of 
syrup  of  the  iodide  of  iron  has  a  happy  effect  in  these  cases  in 
controlling  the  diathesis  and  improving  the  nutrition. 


Now  is  a  good  time  to  subscribe  to  the  journal. 


Clinical  XecturcB, 


DEMONSTRATIONS    IN    OPERATIVE    GYNECOLOGY 
AT   THE    MANHATTAN    SANATORIUM. 

By  Augustin  H.  Goelet,  M.  D.,  New  York. 

ABDOMINAL    HYSTERECTOMY    FOR    LARGE     SUBMUCOUS     FIBROID     OF 
UTERUS. 

THE  first  operation  to-day  is  an  abdominal  section  for  a 
tumor  of  the  uterus  which  has  attained  the  size  of  a 
seven  months  pregnancy.  The  patient  who  is  single  and 
29  years  old  first  noticed  a  slight  enlargement  in  the  lower  part 
of  the  abdomen  a  year  ago.  Since  that  time  it  has  increased 
rather  rapidly,  unusually  so  for  a  tumor  of  this  character  which 
is  undoubtedly  fibroid.  This  leads  me  to  suspect  that  it  is  a 
submucous  growth  projecting  into  the  uterine  cavity  as  these 
tumori  grow  more  rapidly  than  the  interstitial  variety.  That  it 
is  not  a  subperitoneal  growth  I  am  certain. 

The  patient  has  not  menstruated  for  over  a  year  but  for  the 
past  six  months  has  had  a  profuse  and  persistent  hydrorrhoea 
and  her  general  health  has  deteriorated  very  considerably.  The 
operation  should  have  been  done  fully  six  months  ago  but  she 
could  not  be  brought  to  consent,  and  only  consents  now  be- 
cause she  sees  it  is  inevitable  and  believes  it  is  a  last  resort. 
The  differential  diagnosis  of  these  cases  from  pregnancy  in- 
volves a  nice  distinction  and  it  has  occurred  to  good  surgeons 
to  mistake  the  pregnant  for  a  fibroid  uterus,  and  not  discover 
the  mistake  until  the  abdomen  has  been  opened. 

Now  that  the  patient  has  bee»  placed  upon  the  table  and  the 
abdomen  exposed  you  can  see  that  the  symmetrical  enlargement 
resembles  pregnancy  very  closely.  In  addition  to  this  the  soft 
yielding  character  ©f  the  tumor  would  almost  confirm  the  sus- 
picion. But  we  must  bear  in  mind  that  a  foetus  in  utero  at  this 
stage  would  give  us  unmistakable  evidence  of  its  presence  by 
its  movements  or  the  pulsation  of  the  heart  if  it  were  alive  or 
the  placental  soufle  which  could  still  be  heard  if  it  were  dead, 
all  of  which  are  absent  in  this  case. 

We  will  first  cleanse  the  vagina  and  curette  and  cleanse  the 
uterine  cavity  as  far  up  as  can  be  reached  that  the  risk  of  sepsis 


GOELET.— DEMONSTRATIONS  IN  OPERATIVE  GYNECOLOGY.  j  j  ^ 

may  be  lessened  when  they  are  opened  into  from  above.  This 
done  we  proceed  to  open  the  abdomen.  This  tumor,  as  you  see 
it  exposed  in  the  incision,  resembles  very  closely  the  pregnant 
uterus  in  appearance  and  to  the  touch  as  well.  There  are  few 
adhesions  and  they  are  easily  separated,  my  hand  sweeping 
around  the  mass  in  every  direction,  and  I  now  deliver  it  through 
the  abdominal  incision.  I  notice  that  the  wall  is  soft  and  in  a 
state  of  beginning  degeneration  in  places,  and  for  this  reason 
it  would  not  be  safe  to  remove  the  tumor  which  is  within  the 
uterine  cavity,  and  save  the  uterus.  I  have  split  the  anterior 
uterine  wall  near  the  fundus  and  you  see  the  mass  within,  which 
is  distending  the  uterus,  is  m  a  broken  down  degenerated  con- 
dition and  it  would  be  most  unwise  to  attempt  to  remove  it 
without  the  uterus.  I  shall  therefore  do  a  hysterectomy.  I 
shall,  if  possible,  preserve  one  of  the  ovaries  so  as  to  avoid  the 
nervous  symptoms  which  would  otherwise  be  inevitable  in  a 
woman  of  this  age. 

You  see  the  left  ovary  is  already  so  much  diseased  that  it 
must  be  removed,  but  the  right  ovary  is  in  good  condition  and 
may  be  preserved.  We  tie  first  the  left  ovarian  artery  to  the 
outer  side  of  the  ovary,  apply  a  clamp  between  the  ligature  and 
ovary  and  divide  the  intervening  tissue.  I  prefer  silk  for  ligat- 
ing  the  vessels  because  it  is  more  reliable  than  cat-gut,  and  as 
proof  of  this  assertion  I  have  never  had  a  case  of  secondary 
haemorrhage.  When  the  silk  is  left  in  the  peritoneal  cavity  it 
becomes  encysted  and  never  gives  trouble,  provided  it  is  asep- 
tic. But  when  pus  is  encountered  silk  is  a  very  unsafe  mate- 
rial for  ligature  as  it  becomes  infected  and  almost  invariably 
gives  trouble.      In  those  cases  I  always  use  cat-gut. 

The  broad  ligament  is  now  divided  down  to  the  round  liga- 
ment which  with  its  accompanying  artery  is  ligated,  a  clamp 
applied  between  the  ligature  and  the  uterus  and  it  is  divided. 
We  now  make  a  peritoneal  flap  anteriorly  and  posteriorly  with 
the  scapel  by  an  incision  across  the  anterior  and  posterior  face 
of  the  uterus  from  the  left  broad  ligament  over  to  the  right,and 
with  a  gauze  pad  held  in  the  hand  or  in  the  grasp  of  a  pair  of 
sponge  forceps  these  peritoneal  flaps  are  stripped  down  to  the 
pouche  of  douglas  behind  and  to  the  cervico-vaginal  junction 
in  front,  freeing  the  uterus  from  the  bladder.      This  exposes  the 


J  J  -         GOETLET.-DEMONSTRATIONS  IN   OPERATIVE  G YNECOLOGT.- 

base  of  the  left  broad  ligament  and  the  uterine  artery.  A  liga- 
ture is  carried  around  the  vessel  by  means  o  f  an  aneu  rism  needle 
near  the  side  of  the  uterus  for  we  must  be  careful  to  avoid  in- 
cluding the  ureter  which  at  this  point  is  nat  more  than  half  an 
inch  from  the  uterus.  I  shall  leave  the  cervix  in  this  case  be- 
cause it  is  in  a  healthy  condition.  I  prefer  to-  do  this  when  pos- 
sible because  it  affords  support  to  the  bladder,  obviates  hernia, 
and  the  normal  contour  ot  the  vagina  is  preserved. 

The  blood  supply  on  this  side  being  controlled  we  may  now 
divide  the  cervix  at  the  level  of  the  internal  os  by  a  wedge  shaped 
incision  anteriorly  and  posteriorly,and  as  the  right  uterine  artery 
is  exposed  it  is  clamped  and  divided  close  to  the  side  of  the  uter- 
us. The  right  broad  ligament  is  next  divided  close  to  the  side 
of  the  uterus  up  to  the  round  ligament  which  is  clamped  then 
divided  and  next  the  right  ovarian  artery  is  clamped  and  divid- 
ed and  the  whole  mass  is  free.  By  employing  this  technique 
(Howard  Kelly's  metliod)  much  time  is  saved.  Only  three  liga- 
tures have  been  applied  to  the  vessels  on  the  left  and  those  on 
the  right  have  been  clamped  until  the  tumor  has  been  gotten 
out  of  the  way  when  they  may  be  tied  more  conveniently. 

We  will  now  proceed  to  t'e  these  vessels  which  have  been 
clamped  and  close  the  pelvic  roof.  The  cervical  canal  is  dilated, 
and  the  ends  of  the  ligatures  on  the  uterine  arteries  which  have 
been  left  long  are  carried  through  it  to  the  vagina,  and  a  strip 
of  iodoform  gauze  is  carried  through  also,  its  upper  end  being 
folded  across  the  cervical  stump  on  either  side,  as  far  as  the 
stumps  of  the  uterine  arteries  for  drainage.  The  flaps  of  cer- 
vical tissue  are  now  united  by  two  or  three  interrupted  sutures 
of  chromicized  cat-gut.  The  peritoneal  flaps  and  broad  ligaments 
are  next  brought  together  with  a  continuous  suture  of  plain  cat- 
gut begining  on  the  left  and  terminating  on  the  right.  I  pre- 
fer to  close  the  pelvic  roof  in  this  manner  in  all  cases  where  there 
is  no  necessity  for  draining  the  peritoneal  cavity. 

The  patient  is  lowered  from  the  Trendelenburg  position  and 
the  cavity  is  flushed  with  hot  normal  solution,  which  is  not 
sponged  out. 

My  method  of  closing  the  abdominal  wound  differs  in  one  im- 
portant particular  from  that  ordinarily  employed,  in  that  I  in- 
clude the  muscle  in  the  continuous  suture  which  unites  the  peri- 
toneal margins  and  the  fascia  is  united  separately     by    another 


GOELET.— VENTKAX,  SUSPEN  SION  OF  UTERUS  ETC.        j  j  t 

irow  of  continuous  suture  covering  theother  row  over.  Chro- 
micized  cat-gut  is  used  for  this  purpose  and  one  strand 
■ssrves  for  both  layers  and  but  one  knot  is  made,  that  at 
the  upper  angle  where  the  suture  is  started.  Deep  sutures  of 
silk-worm  gut  including  the  whole  thickness  of  the  abdominal 
wall  are  inserted  first  and  tied  afterwards. 

I  prefer  this  method  because  it  units  mure  surely  the  different 
important  layers  of  the  abdominal  wall,  insures  firm  union,  a 
strong  cicatrix,  and  I  have  never  had  a  hernia  after  any  of  my 
abdominal  operations. 

VKNTRAL  SUSPENSION   OF   UTERUS  FOR  FIXED    RETROFLEXION. 

The  second  operation  today  is  for  a  reti'ofiexed  uterus  which 
is  bound  down  by  adhesions,  and  it  is  possible  that  I  vinll  be  com- 
pelled to  remove  the  right  ovary  which  is  diseased,  has  resisted 
all  treatment  and  continues  to  be  enlarged,  painful  and  sensitive. 

The  patient,  who  is  26  years  old,  has  been  a  constant  sufferer 
for  many  and  years,  nothing  has  given  her  more  than  temporary 
relief.  She  has  had  very  careful  preparation  for  the  operation 
since  she  has  been  under  my  observation,  with  a  view  to  remov- 
ing all  exudation  and  infiltration  surrounding  the  uterus  and 
relieving  as  much  as  possible  all  inflammatory  action  ;  hence  she 
is  in  a  very  nauch  better  condition  than  she  was  before,  and  her 
suffering  has  been  correspondingly  much  lessened.  She  is,  there- 
fore, in  a  very  favorable  condition  for  operation.  We  will  be- 
gin by  curetting  the  uterus,  though  this  has  been  done  before, 
because  there  is  some  endometritis  remaining.  This  endomet- 
tritis  has  been  persistent  because  the  displacement  and  the  fixa- 
tion interferes  with  the  return  circulation  and  a  constant  hyper- 
aemia  is  maintained. 

The  operation  which  is  to  be  preferred  in  these  cases  is  ven- 
tral suspension.  The  abdomen  is  opened  by  an  incision  which 
need  not  be  more  than  two  and  a  half  inches  long,  the  uterus  is 
freed  and  the  fundus  is  brought  up  to  the  lower  angle  of  the  in- 
cision and  attached  by  two  sutures  to  the  abdominal  peritoneum. 
When  done  by  a  properly  perfected  technique  the  surface  of  at- 
tachment is  not  broad,  but  it  is  firm.  Hence,  though  the  uter- 
us is  close  to  the  abdominal  wall,    the   narrow   attachment   per- 

NoTE — Eight  months  have  elapsed  since  this  operation,  the  patient 
has  made  an  excellent  recovery,  has  regainedher  healthfully,  and  there 
has  been  no  nervous  symptoms. 


J  ,  5  GOELET.-VENTKAL  SUSPENSION  OF  UTERUS,  ETC. 

mits  it  to  sag  down,  and  settle  into  a  nearly  normal  position  as 
the  peritoneal  folds  on  both  the  uterine  surface  and  the  abdomi- 
nal wall  stretch  out,  and  it  remains  suspended  fairly  movable, 
(not  fixed)  by  a  strong  band,  and  subsequent  pregnancy  will  not 
be  interferred  with. 

The  abdominal  cavity  being  now  opened  the  index  and  middle 
fingers  of  the  left  hand  are  inserted  into  the  pelvis  behind  the 
uterus,  the  adhesions  are  broken  up  and  the  fundus  is  brought 
up  into  the  wound  and  held  there  by  grasping  it  with  a  pair  of 
angular  tenaculum  forceps.  The  right  ovary  is  now  brought  up 
and  we  find  it  in  a  state  of  septic  degeneration,  therefore  it  must 
be  removed.      The  other  ovary  is  fortunately  in  good  condition. 

The  peritoneum  on  each  side  at  the  tovv^er  angle  of  the  wound 
is  now  seized  with  artery  clamps  and  drawn  out,  then  with  a 
small  curved  needle  carrying  medium  sized  silk,  a  suture  is  in- 
serted through  the  peritoneum  and  subperitoneal  fascia  at  the 
lower  angle  of  the  wound  on  the  left,  then  on  the  posterior  face 
of  the  fundus  and  again  through  the  peritoneum  and  subperi- 
toneal fascia  on  the  right  at  a  point  opposite  the  point  of  in- 
sertion on  the  left.  Both  ends  of  this  suture  are  now  grasped 
with  a  pair  of  pressure  forceps,  and  a  second  suture  is  inserted 
in  the  same  manner  a  quarter  of  an  inch  above  the  first  on  the 
peritoneal  -surface  and  a  quarter  of  an  inch  behind  the  other  on 
the  uterine  fundus.  We  are  now  ready  to  tie  these  sutures  and 
close  the  abdominal  wound.  Deep  sutures  of  silkworm-gut  in- 
cluding the  whole  thickness  of  the  abdominal  wall  and  perito- 
neum are  first  inserted.  These  prevent  dragging  away  of  the 
peritoneum  from  the  abdominal  wall  before  complete  union  of 
the  wound  has  taken  place.  The  silk  sustaining  sutures  are  now 
tied,  bringing  the  uterus  close  up  to  the  abdominal  wall,  but  ob- 
serve that  the  uterus  is  attached  by  its  posterior  face  instead  of 
by  its  anterior  face  as  in  the  usual  ventrofixaLion.'  ,^  Hence  it  is 
tilted  forward,  and  when  the  patient  resumes  the  erect  position 
the  intra-abdominal  pressure  comes  against  its  posterior  face. 
The  peritoneum  is  next  united  by  a  continuous  suture  of  chro- 
miciz'id  cat-gut  closing  over  the  sustaining  sutures  and  burying 
them  in  the  peritoneal  cavity.  Next  the  fascia  is  united  with 
the  same  continuous  suture  as  in  the  first  case  operated  upon 
today  and  finally  the  interrupted  silkworm  sutures  arc  tied. 
The  uterus  remains  close  to  the  abdominall   wall  until  union 


HOMING  PIGEONS  IN  MEDICAL  PRACTICE.  ny 

of  the  abdominal  wound  has  taken  place  and  the  deep  stlkworm- 
gu  sutures  dave  been  removed.  Union  has  then  taken  place  at 
the  point  of  attachment  of  the  uterus  between  the  peritoneum 
on  the  posterior  face  of  the  fundus  and  the  abdominal  perito- 
neum. Later  when  the  weight  of  the  uterus  is  exerted  against 
this  attachment  the  abdominal  peritoneum  and  that  upon  the 
uterus,as  well  pulls  out  and  stretches  forming  a  fold  or  band  of 
about  an  inch  in  length.  This  band  becomes  sufficiently  firm  to 
support  the  weight  of  the  uterus,  which  remains  suspended  in  a 
nearly  normal  position  fairly  movable. 

The  advantage  then  of  this  suspension  over  the  ordinary  ven- 
trofixation is  that  the  uterus  is  subsequently  movable  and  is 
tilted  forward  normally,  instead  of  being  fixed  by  its  anterior 
face  against  the  abdominal  wall. 

The  mortality  of  this  operation  independent  of  the  disease  of 
the  appendages  v.hich  may  cause  fixation  of  the  uterus   is  prac- 
tically nil.      I  have  never  lost  one  of  these  cases,  and  the  opera- 
tions have  been  invariably  successful, 
io8  West  73rd  St. 


Homing  Pigeons  IN  Medical  Practice. — Dr.CharlesL.  Lang 
of  Meridian,  N.  Y.,  gives  to  the  Philadelphia  Medical  J ourjial  his 
experience  with  homing  pigeons  as  messengers  to  convey  to  him 
information  as  to  the  condition  of  patients  at  a  distance  from 
his  home.  Two  or  three  of  the  birds  are  left  at  the  house  of 
the  patient  and  some  member  of  the  family  or  the  nurse  is  in- 
structed to  write  the  hour  pulse,  temperature,  respirations  and 
other  information  upon  a  slip,  told  it,  and  slip  it  under  the  band 
which  the  bird  wears  around  its  leg.  The  bird  in  pushing  its 
way  into  its  house  rings  an  electric  bell,  thus  announcing  its 
arrival.  He  can  be  certain  that  in  this  way  a  message  will  reach 
him  at  the  rate  of  a  mile  every  one  or  two  minutes.  He  says 
there  is  no  mystery  or  difficulty  about  it,  the  main  point  being 
to  procure  the  best  of  stock  and  not  to  train  the  young  birds 
until  they  are  at  least  four  months  old,  thus  giving  them  time 
to  become  used  to  their  surroundings  and  to  develop  their  brains 
sufficiently  to  stand  the  strain  of  training.  He  offers  to 
the  information  he  can  to  any  who  desire  further  light  upon  the 
subject. 


NORTH  CAROLINA  MEDICAL  JOURNAL, 

ROBERT  D..   JEWETT,  M.D.,  Editor. 


DEPARTMENT  EDITORS.. 

(      H.  T,  Bahnson,  M.D.,  Salem,  N.C. 
SURGERY;     \     R.  L.  Gibbon, M.D.,  Charlotte,  N.  C. 

{     J.  Howell  W  ay,  M.D.,  Waynesville,  N.  C. 

NERVOUS  DISEASES:— J   llison  Hodges,  M.D.,  Rcihmond,  Va. 
PRACTICE  OF  MEDICINE.  ]    S-  Westry  Battle,  M.D.,  U.  S.  N., 

rMJcrTT-T-TJTnc      J      GEORGE  G.  THOMAS,  M.D.,  Wilmington,  N.  C. 
UB!3iiLiKiCfc>.      "I     ^   L.  Payne,  M.D.,  Norfolk,  Va. 

(      H.  S.  LOTT,  M.D.,  Winston.  N.  C. 
GYNAECOLOGY:     \      J.   W.  Long,  M.D.,  Salisbury,  N.  C. 
(     H.  A.  ROYSTER,  M.D.,  Raleigh,  N.  C. 

PATHOLOGY:— Albert  Anderson,  M.D.,  Wilson,  N.  C. 
PEDIATRICS:— J.  W.  P.  Smithwick,  M.D.,  La  Grange.  N.  C. 
TRANSLATION  AND  FOREIGN  REVIEWS: 
Richard  H.  Whitehead,  M.  D.  ,  Chapel  Hill,  N.  C. 

This  Journal  is  published  on  the  fifth  and  twentieth  of  each  month,  and 
any  subscriber  tailing  to  receive  his  copy  promptly,  is  asked  to  announce  the 
fact  to  this  office. 

Cuts  will  be  provided  for  any  original  communications  (sent  to  this  Jour- 
nal only)  requiring  illustrations,  free  of  cost  to  the  author. 

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ton, N,  C. 


EbitoriaL 


THE  SERUM  DL\GNOSIS  OF  YELLOW  FEVER. 


The  great  progress  made  by  the  epidemic  of  yellow  fever  in 
the  South  in  1897  before  the  nature  of  the  disease  was  discovered 
(it  is  now  said  by  the  committee  of  investigation  that  the  disease 
began  in    April,    being    brought    from  Guatemala  by    a  family 


iijjrroKiAij.  J  J  q 

^ho  came  to  Ocean  Springs,)  and  the  doubts  in  regards 
to  tiie  diagnosis,  even  by  experts,  of  suspicious  cises, 
and  the  fact  that  cases  of  dengue  were  called  yellow 
fever  and  cases  of  yellow  fever  called  dengue  by  men  of  con- 
siderable ixpsrienci  in  the  treat.-neit  of  both  diseases,  .ire  well 
remembered.  These  facts  show  the  importance  of  some  certain 
and  early  method  of  diagnosis  of  this  disease.  The  appearance 
of  the  epidemic  so  soon  after  the  announcement  by  Sanurelli  of 
the  discovery  of  the  specific  pathogenic  agent  of  yellow  fever, 
and  the  peculiar  agglutinative  reaction  of  the  blood  of  an  infec- 
tious disease  with  its  specific  micro-organism,  as  demonstrated 
by  Widal  in  the  case  of  typhoid  fever,  presented  an  opportunity 
for  the  practical  test  of  this  method  of  diagnosis  in  yellow  fever. 
A  series  of  experiments  along  this  line  was  made  by  Drs.  P.  E. 
Archinard  and  John  J.  Archinard,  Bacteriologist  and  Assistant 
Bacteriologist,  respectively,  to  the  Louisiana  State  Board  of 
Health,  and  Capt.  R.  S.  Woodson,  M.  D.,  U.  S.  A.,  who  pub- 
lished in  the  February  issue  of  the  Netv  Orleans  Medici! and  Sur- 
gical Journal  a  detailed  report  of  their  investigations.  The  re- 
port shows  very  careful  work  .nd  embraces  a  series  of  one  hun- 
dred cases.  The  first  fifty  specimens  of  blood  were  taken  from 
typical  yellow  fever  cases  at  the  isolation  hospital  and  from  pri- 
vate practice;  the  second  fifty  were  cases  of  typhoid  fever,  ma- 
laria, and  yellow  fever.  The  Johnston  dried  blood  method  on 
glass  slides  was  followed, and  in  seme  cases  the  slides  were  kept 
two  months  before  the  application  of  the  test.  The  physical 
agencies — heat,  cold,  evaporation,  contact  with  foreign  bodies, 
etc. — were  eliminated.  The  cultures  used  were  eighteen  hours 
■old  and  very  active.  Cessasion  of  motion  as  well  as  agglutina- 
tion were  made  the  criteria  of  the  reaction,  and  the  application 
was  made  both  to  cultures  of  the  bacillus  icteroides  and  bacillus 
typhosus. 

In  twenty  cases  the  proportion  used  was  one  of  diluted  blood 
to  five  of  bouillon  culture  (1-5).  The  proportion  used  in  the 
next  ten  was  the  same,  but  followed  by  1-40  as  a  control.  In 
the  next  twenty  cases  i-io  was  used  with  bacillus  icteroides, 
followed  by  i  40  with  both  bacilli. 

In  the  first  series  there  was  the  following  result:  icteroides — 
agglutination  17;  partial  agglutination  2;  negative  i.  Typhosus 
agglutination  18:  negative  2. 


20  EDITORIAL. 


In  the  second  series  the  result  with  1-5  was  as  follows: /V/<?r^/- 
des — agglutination  6;  negative  4.  Typhosus — agglutination  4; 
negative  6.  With  1-40  there  was  agglutination  in  five  cases  with 
icteroides  and  none  with  typhosus. 

In  the  third  series  of  twenty  cases  tested  with  i-io  there  was 
agglutination  in  18  cases  with  icteroides;  with  1-40  there  was  ag- 
glutination of  icteroides  \x\  16,  slight  agglutination  in  i,  a"d  neg- 
ative in  3  ;  with  1.40  there  was  agglutination  of  typhosus  in  6  cases 
slight  aggultination  in  i,  and  negative  in  13.  Of  the  six  cases 
of  typhosusgiving  agglutination  there  was  present,  or  a  history 
of  typhoid  fever  in  four,  and  in  the  remaining  two  cases  there 
was  no  agglutination  of  icteroides. 

Of  the  fifty  miscellaneous  cases  there  were 
Typhoid  suspects  35,  with  agglutination  of  typhosus  in  26,  of 
icteroides  in  2,  and  ot  both  in  9. 

Yellow  Fever  suspects  3,  with  agglutination  of  icteroides  in 
all,  and  of  typhosus  in  none. 

Malarial  suspects  12,  with  plasmodia  present  in  4  cases,  and 
agglutination  of  icteroides  in  5.  No  agglutination  of  typhosus. 
There  was  no  agglutination  in  cases  where  plasmodia  were  found 
and  no  plasmodia  where  there  was  agglutination. 

Of  this  series  there  were  four  cases  in  which  there  was  neither 
aggultination  of  either  bacillus  nor  plasmodia  present. 

From  their  observations  the  authors  reach  the  following  con- 
clusions; (i)  Our  work  demonstrates  the  practical  value  of 
serum  diagnosis  in  yellow  fever.  (2)  It  may  be  utilized  as  early 
as  the  second  day,  and  be  exceptionaly  present  as  late  as  nineteen 
years  after  the  disease.  (3)  That  a  dilution  of  1-40  with  a  time 
limit  oi  one  hour  is  to  be  preferred  for  accuracy  of  diagnosis. 
(4)  That  the  dried  blood  of  Wyatt  Johnston  is  perfectly  satis- 
factory. (5)  That  the  serum  diagnosis  of  yellow  fever  should 
be  instituted  in  all  countries  wherein  the  disease  may  exist  en- 
demically,  or  which  may  be  visited  occasionally  by  epidemics. 
(6)That  it  is  especially  valuable  at  the  beginning  of  an  epidemic 
in  the  diagnosis  of  early  and  doubtful  cases. 

These  gentlemen  deserve  much  praise  for  the  thoroughness 
with  which  they  have  carried  out  their  investigations,  and  have 
apparently  established  a  reasonably  sure  method  of  diagnosis  of 
yellow  fever.  However,  as  is  suggested  by  the  editor  of  the  New 
Orleans  Medical  and  Surgical  Journal^  "the  necessity  will   remain 


REVIEW  OF  CURRENT  LITERATURE.  I  2 1 

for  the  study,  as  soon  as  the  opportunity  presents,  of  tlie  action 
of  blood  from  undoubted  cases  of  dengue  upon  the  bacillus  icter- 
oides,  inasmuch  as  there  is  a  bare  possibility  of  some  connection 
between  the  two  diseases.  Should  dengue  blood  give  negative 
results  as  typhoid  and  malarial  blood  arc  proven  to  do,  then  the 
test  can  be  adopted  as  confidently  as  the  Widal  test  for  typhoid 
fever." 


•Keviews  anb  Book  IRotices. 


Index  Catalogue  of  the  Library  of  the  Surgeon  General's  office. 
United  States  Army.  Authors  and  subjects.  Second  series.  Vol.  II. 
B-Bywater.  Government  Printing  office,  Washington.     1897. 

The  work  of  indexing  this  great  library  goes  on  apace,  and 
the  fact  that  the  present  volume  embraces  nearly  a  thousand 
pages  and  covers  only  the  letter  "B"  evidences  the  tremen- 
dous growth  of  the  library.  The  value  of  such  a  library, 
properly  catalogued,  to  the  medical  profession  of  the  country 
cannot  be  estimated.  This  volum.e  includes  15,732  author  titles, 
representing  6,383  volumes  and  14,802  pamphlets.  It  also  con- 
tains 5,774  subject  titles  of  separate  books  and  pamphlets,  and 
21,725  titles  of  articles  in  pcroidicals.  One  feature  worthy  of 
notice  is  the  very  small  proportion  of  matter  furnished  hy  Eng- 
lish speaking  authors.  Thus  opening  the  volume  at  random  we 
find  under  the  subject  of  Tumors  of  Bone  55  separate  books 
and  pamphlets  catalogued  and  not  one  by  an  English  speaking 
author;  of  83  articles  in  journals  on  the  same  subject,  only  22 
are  in  English. 

A  System  of  Medicine  by  many  Writers.  Edited  by  Thomas 
Clifford  Allbutt,  M.  A.,  M.  D.,  LL.  D.,  F.  R.  S.,  F.  L.  S.,  F.  S.  A.;  Regius 
professor  of  Physic  in  the  University  of  Cambridge,  Fellow  of  Gonville  and 
Caius  College.  Vol.  IV.  Royal  octavo,  992  pages.  Cloth  $5.00.  The  Mc- 
Millan Company,  New  York.  1897. 

The  present  volume  of  this  most  excellent  System  of  Medicine 
is  divided  into  two  main  parts:  I.  General  diseases  of  Obscure 
Causation;  II.  Diseases  of  Alimentation  and  Excretion.  The 
list  of  contributors  embraces  many  of  the  most  eminent  physi- 


REVIEWS   AND  BOOK  NOTICES. 

cians  and  surgeons  of  England.  In  the  first  part  are  considered 
rheumatism  in  its  various  forms,  including  gonorrhoeal  rheuma- 
tism;  rickets  ;osteomalacia;  gout  ;diabetes  mellitus  and  insipidus; 
lardaceous  disease. 

The  second  part  is  subdivided  into  sections  on  (r)  Dis- 
eases of  the  Stomach;  (2)  Diseases  of  the  Peritoneum  ;  (3)  Dis- 
eases of  the  Bowels.  There  are  also  special  chapters  which  dis- 
cuss Subphrenic  Abscess;  Diaphragmatic  Hernia;  Abdominal 
Diagnosis  from  a  Gynaecological  Standpoint;  and  Enteroptosis. 
An  exhaustive  and  interesting  paper  on  Perityphlitis,  which  name 
the  author  prefers  to  the  "uncouth"  term  "appendicitis,"  is  pre- 
sented from  the  pen  of  Mr.  Frederick  Treves.  In  writing  of  the 
treatment  Mr.  Treves  says,  "The  use  of  the  exploring  needle — 
which  has  been  much  advocated  by  American  surgeons — is  to  be 
very  strongly  condemned.  This  needle  is  thrust  into  the  iliac 
region  of  the  abdomen, often  to  the  depth  of  three  or  four  inches, 
is  passed  in  different  directions,  and  is  sometimes  introduced 
three  or  four  times  at  one  sitting.  The  object  is  to  discover  pus 
In  the  first  place  it  may  be  pointed  out  that  deep-seated  pus,  in 
sufficient  quantity  to  demand  surgical  interference,  may  be  diag- 
nosed by  other  means;  and  that  if  an  exploration  must  be  made 
it  would  be  safer  to  trust  to  a  cautious  incision  than  to  a  series 
of  plunges  made  in  the  dark."  The  author  in  thus  stating  that 
this  procedure  is  "so  much  advocated  by  American  surgeons" 
does,  we  think,  an  injustice  to  the  surgeons  of  America,  who 
easily  stand  abreast  of  any  in  the  march  of  surgical  science.  We 
do  not  believe  there  could  be  found  one  surgeon  of  any  promi- 
nence in  this  country  who  would  countenance  such  a  procedure 
as  is  described  by  Mr.  Treves. 

We  can  commend  this  volume  as  standing  well  in  line  with 
the  preceding  volume  which  we  had  the  pleasure  of  noticing  in 
the  issue  of  December  5th.  We  look  forward  with  pleasure  to 
the  receipt  of  the  remainder  of  the  work,  which  the  author  an- 
nounces as  in  an  advanced  state  and  will  be  published  with  as 
little  delay  as  possible. 

Announcewent  of  New  Books. — The  following  books  are 
in  press  and  will  soon  be  issued  by  the  publishers,  J.  B.  Flint 
&  Co.,  104  Fulton  Street,  New  York. 


THERAPEUTIC  HINTS. 


123 


Flint's  Encyclopedia  of  Medicine  and  Surgery. — Second  (1898)  edition, 
1555  pages,  revised  with  the  assistance  of  fifty-six  contributors  and  thor- 
oughly in  line  with  recent  advances  in  medical  science.  Cloth  $5,  leather  or 
half  morrocco  $6. 

Hartley-Auvard  System  of  Obstetrics. — Third  (1898)  edition,  436 
pages,  543  illustrations.  Revised  by  Dr.  John  D.  Hartley.  This  work  is 
essentially  Auvard,  and  embodies  the  author's  personal  experience,  the  text 
is  clearly  pictured  by  hundreds  of  original  drawings  to  be  found  in  no  other 
book.     Cloth  $4,  leather  or  half  morrocco  $5. 

Pozzi  SvsTEM  OF  GYNAECOLOGY. — Third  edition.  Revised  by  Dr.  John 
D.  Hartley. 


^berapeutlc  1bint0. 


Measles. — To  develop  the  eruption  and  allay  incessant  laryn- 
geal cough: 

Ijfc — Syrup  of  hydriodic  acid, 
Dover's  syrup, 

Syrup  of  tolu aa   5  1. 

The  Dover's  syrup  is  to  be  lessened  for  infants.  During  the 
eruptive  stage  and  throughout  a  broncho-pneumonia: 

:^— Pot.   acet 3  ij. 

Spiritus  mindereri. 

Aquae  camphor aa   3  iij. 

Give  a  teaspoonful  every  hour  to  a  child,  and  a  tablespoon- 
ful  to  an  adult,  with  plenty  of  water.  In  case  of  sepsis,  diph- 
theria, or  debility,  add  one  drachm  of  the  tincture  of  chloride 
of  iron. — John  A,  Larraber,  Pediatrics. — Med.  Record. 

BaLSAM  OF  Peru  in  Itch. — At  the  recent  annual  meeting  of 
the  Societe  Francaise  de  Dermatologie  et  de  Syphilograph  {^Sem. 
Med.),  Julian  stated  that  he  used  balsam  of  Peru,  according  to 
the  method  followed  by  Peters  and  Tanturri,  in  about  300  cases 
of  itch.  Balsam  of  Peru  contains  an  essential  oil,  the  vapor  of 
which  is  extremely  toxic  to  the  acarus.  The  patient  is  rubbed 
in  the  evening  for  15  or  20  minutes  with  the  balsam;  it  is  not 
necessary  to  rub  hard  as  the  vapor  is  sufficient  to  kill  the  para- 
site.    The  patient  sleeps  afterwards  in  a  nightshirt  impregnated 


GYNECOLOGY  AND  ABDOMINAL  SURGERY. 
124 

with  balsam  of  Peru, and  the  next  morning  he  is  soaped  all  over 
and  has  a  bath.  This  treatment  is  particularly  useful  in  patients, 
affected  in  secondary  eczematoid  and  dermatic  lesions  and  in 
weakly  persons,  in  the  subjects  of  heart  disease,  in  pregnant 
women,  and  in  nurslings. — Ex. 


Laryngism  vs  Stridulus: 
IJ — Potassium  Citrate 
Powdered  Ipecac 
Tincture  Opium 
Syrup  .... 
Distilled  Water    . 


80  grn.  (5.2  gme.) 
3  dr.    (11.5  gme.) 
16  min.  (i  c.  c.) 

3  fl.  dr.  (11. 5  c.c.) 

4  fl.  oz.  (120  c.  c.) 


Teaspoonful  every  hour. — Am.  Med.  and  Surg.  Bull. 


IRevlcw  ot  Current  Xiterature. 


GYNECOLOGY  AND  ABDOMINAL  SURGERY. 

IN  CHARGE  OF 

H.  S.  LoTT,  M.  D.,  J.  W.  Long,  M.  D. 

Hubert  A.  Royster,  M.  D. 


A  New  Method  of  Intestinal  Anastomosis —(Horseley,  New- 
York  Polyclinic,  Dec.'97).  The  essential  points  after  resecting- the  bowel 
and  mesentery,  are:  The  ends  of  the  bowel  are  placed  side  by  side, 
the  ends  opening-  in  the  same  direction,  and  being  in  contact  along 
their  free  surfaces  opposite  the  mesentery.  A  pair  of  forceps  inserted 
into  the  ends  holds  them  in  this  position.  The  thumb  and  finger  of  the 
left  hand  is  now  inserted  along  side  the  forceps  and  over  the  fingers  as 
a  bobbin  a  continuous  suture  of  fine  silk  is  placed  beginning  near  the 
mesenteric  attachment  and  passing  around  on  the  peritoneal  surfaces 
to  the  opposite  point  on  the  other  side.  The  U-shaped  septum  em- 
braced by  this  suture,  being  the  partheld  by  the  forceps  andfingers,  is 
now  cut  away  and  the  edges  sutured  with  an  overhand  silk  suture. 
This  suture  is  continued  entirely  around  the  resected  ends  of  the  bowel 
followed  by  continuing  the  Gushing  suture  to  its  starting  point. 


GYNECOLOGY  AND   ABDOMINAL  SUKGERY.  j2r 

The  author  claims  for  the  operation  that  it  is  a  suture  method,  it  can 
be  done  in  twenty  minutes,  the  bowel  being  cut  and  sutured  in  the 
peculiar  way  described  above,  the  diameter  of  the  sutured  parts  is 
greater  than  the  normal  and  so  obviates  stricture,  applying  the  sutures 
over  the  fingers  increases  the  safety  of  the  suturing,  and  the  internal 
row  prevents  hemorrhage.  The  illustrations  accompanying  this  article 
make  the  text  very  plain.  ( It  is  to  be  noticed  that  this  opera- 
tion is  but  a  modification  of  the  old  suture  method.  Whether  or  not 
it  will  stand  the  crucial  test  of  application  in  a  large  number  of  cases 
in  the  hands  of  other  men  remains  to  be  seen.  Theoretically  thei-e  are 
some  objections  to  the  method  of  Dr.  Horseley,  but  one  should  not  con- 
demn a  procedure  thas  holds  out  the  advantages  claimed  by  the  author 
of  this  operation  too  hurriedly.  To  judge  intelligently  one  should  do 
the  operation  experimentally  on  the  lower  animals  as  did  Dr.  Horseley. 
There  is  no  more  trying  operation  to  the  abdominal  surgeon  than  an 
intestinal  resection,  and  unquestionably  the  best  method  yet  devised 
is  the  sutui'e  method.  The  writer  has  had  some  experience  in  this  class 
of  work  and  unhesitatingly  gives  precedence  to  the  interrupted  suture 
over  any  and  every  form  of  mechanical  device  with  which  he  is  familiar. 
One  should  never  do  an  abdominal  section  v/ithout  being  supplied  with 
several  dozen  intestinal  needles  already  threaded.  Thus  prepared,  an 
intestinal  resection  may  be  done  quickly,  securely,  and  satisfactorily. ) 

J.  W.  L. 

A  New  Apparatus  in  Enterorrhaphy.— Wackerhagen  (N.  Y. 
Med.  Jour.  )  describes  a  new  support  for  the  sutured  ends  of  the  intes- 
tine in  doing  anastomosis.  It  consists  of  a  small  rubber  bag  to  which 
is  attached  centrally  a  tube.  On  inflating  the  bag  by  means  of  a  rubber 
bulb,  it  is  distended,  more  at  the  extr  emities  than  at  the  middle, 
thus  assuming  somewhat  a  dumb-bell  shape.  The  bag  is  introduced 
collapsed  into  the  ends  of  the  intestine  to  be  united,  and  then  inflated. 
The  inflating  tube  is  tied  close  to  the  bag  and  cut  short.  After  the  in- 
testine has  been  properly  sutured  a  hypodermic  needle  is  introduced 
through  the  intestinal  wall  into  either  end  of  the  bag  and  the  air 
allowed  to  escape.  The  bag  can  then  easily  pass  from  the  intestine. 
Or  the  inflating  tube  can  be  held  with  forceps  and  when  the  suturing 
has  been  nearly  completed,  the  forceps  removed  and  the  air  allowed  to 
escape,  the  small  opening  being  closed  with  the  intestine  in  a  collapsed 
state.  The  bags  are  made  by  Tiemann,  of  New  York.  They  are  of 
different  shapes  for  end  to  end,  end  to  side,  and  side  to  side  anasto- 
mos-is. 

Gun-shot  Wound  of  Brain  with  Recovery. —Dr.  W.  H,  May- 
field  of  St.  Louis  ( Amer.  Jour.  Surg,  and  Gynecol. )  lately  performed 
a  most  remarkable  operation  at  his  sanitarium.  The  patient,  a  boy 
aged  7  years,  was  shot  with  a  Winchester  rifle,  the  ball   striking  the 


126 


PRACTICE  OF  MEDICINE, 


forehead  just  above  the  left  eye  and  passing  through  the  brain.  He 
was  brought  to  the  hospital  aphasic,  hemiplegic  and  only  partially 
conscious,  though  several  days  had  elapsed  since  the  accident.  Dr.  May 
iield  opened  up  the  wound  of  entrance  to  allow  the';4ischarge  of  some- 
pus  and  broken-down  brain  tissue,  determined  the  course  of  the  ballby 
probing  and  decided  to  open  the  skull  posteriorly — in  the  occipital 
region  of  the  opposite  side,  the  bullet  having  apparently  pased  through 
the  falx.  He  trephined  and  found  the  ball  without  diiuculty.  At  the 
present  time,  three  weeks  after  operation,  the  boy  is  in  excellent  con- 
dition; speech  has  returned,  paralysis  of  the  leg  has  entii-ely  disap- 
peared and  the  arm  is  rapidly  regaining  its  usefulness. 


PRACTICE  OF  MEDICINE. 

IN  CHAKGE  OF 

Westry  Battle,  M.D.,  U.  S.  N.,  Asheville,  N.  C. 


The  Treatment  of  Asthma  by  Anti-Dipiitheritic  Serum.— Dr. 
ReVilliod  ( Revue  Medicale  de  la  Suisse  Romande  of  Dec.  20.  1897 ) 
proposes  to  treat  asthma  by  the  injection  of  anti-diphtheritic  serum. 
He  bases  his  treatment  on  the  f  s,ct  that  after  injections  of  serum  an  in- 
creased secretion  from  all  mucous  membranes  is  noticed  and  that  the 
channels  through  which  drugs  are  eliminated  are  those  where  their 
therapeutic  action  is  exerted,  hence  the  beneficial  action  of  the  iodides 
in  many  asthmatic  cases  is  due  to  their  helping  the  patient  to  eliminate 
the  particular  noxious  substances  through  the  respiratory  tract.  He 
ascribes  the  good  effect  arising  from  the  use  of  the  serum  to  a  similar 
physiological  action  and  not  to  any  supposed  antitoxic  property.  He 
reports  the  treatment  of  several  cases  of  varied  duration  in  which  the 
patients  were  benefited  soon  after  the  first  injection  and  all  presented 
a  marked  improvement,  if  not  a  complete  cure  at  the  end  of  from  3  to 
10  injections.  He  ends  up  by  saying  that  although  no  definite  conclu- 
sion can  be  drawn  from  such  a  limited  number  of  cases  still  he  be- 
lieves the  treatment  worthy  of  the  consideration  of  the  profession. 

Treatment  OF  Tabes  Dorsalis.— Dr.  Daniel  P.  Brower.  in  the  Jour- 
nal of  the  Anerioao  ^vl  3  lLc.il  x\.-jsociation  of  Jan.  22.  1898,  writes  aninter- 
esting  article  on  the  treatment  of  tabes  dorsalis.  He  first  considers  the 
question  of  climate  and  recommends,  -whenever  practicable,  permanent 
residence  in  a  M^arm,  dry,  equable  climate  of  low^  level  or  moderate 
altitude.  In  cases  where  it  is  impossible  for  the  patient  to  take  up  a 
permanent  residence  in  such  a  climate  he  recommends  an  ocean  voyage 
or  the  sojourn  during  the  spring  months  in  the  Ozark  Mountains  of 
Missouri,  in  the  mountains  of  North  Carolina,  orin  a  similar  moderate 
altitude;  at  Atlanta,  Ga.,  Los    Angeles,  Cal.,    or  in  similar  low    level 


PRACTICE  OF  MEDICINE.  j27 

climates.  Rest  is  essential,  when  the  disease  is  progressing  rapidly, 
absolute  rest  in  bed  with  daily  massage  and  faradic  exercise  of  the 
muscles  for  a  period  of  from  6  to  8  weeks,  then  if  the  case  is  one  of  slow 
pro!ji-ession,  the  partial  resumption  of  ordinary  avocations.  But  in 
every  case  a  part  of  eachday  should  be  spent  in  the  recumbent  position. 
Excessive  mental  and  physical  work  to  bo  avoided,  soKual  excess  es- 
pecially harmful,  seemingtocontributeto  optic nei^ve  atrophy.  Traumas, 
especially  concussion  of  the  spine,  to  be  avoided.  The  training  of  the 
muscles  after  the  system  proposed  by  Fraenkel  is  endorsed  by  him. 
Special  attention  should  be  paid  to  the  action  of  the  gastro-intestinal 
tract  and  the  food-stuffs  should  be  regulated  accordingly.  Excesses  in 
alcohols  or  smoking  to  be  avoided.  Electricity,  static  from  machine 
of  high  potential,  by  insulation  and  by  heavy  sparks  from  spine  and 
lower  extremities;  faradization,  of  skin  by  wire  brush  electi-ode.  Sus- 
pension, after  Motschutkowskis  system  of  service  when  disease  is  ad- 
vancing after  a  more  or  less  lengthened  stationary  period,  as  is  the 
stretching  of  the  sciatic  nerve  by  manipulations  in  like  cases.  Vigor- 
ous anti-syphilitic  treatment  beneficial  where  infection  is  recent  and 
symptoms  have  developed  rapidly,  but  are  contra-indicated  where  de- 
velopment has  been  slow  or  where  a  long  interval  has  elapsed  since 
primary  symptoms.  It  should  consist  of  iodide  of  potassium  in  as 
large  doses  as  possible,  together  with  the  hypodermic  use  of  mercury. 
As  an  alterative  he  places  the  greatest  reliance  in  the  chloride  of  gold 
and  sodium,  believing  that  this  drug  has  the  power  to  arrest  the  prog- 
ress of  connective  tissue  hypertrophy  in  the  cord  as  well  as  in  the  liver 
and  kidneys;  the  best  dose  is  a  tenth  of  a  grain  three  times  a  day 
either  alone  or  combined  with  resin  of  guiac,  three  grains.  In  urgent 
cases  he  advocates  the  use  of  a  freshly  prepared  hypodermic  solution 
in  order  to  avoid  to  a  greater  extent  the  destruction  of  the  drug  in  the 
stomach.  In  cases  which  cannot  take  the  above  he  uses  one  of  the  pre- 
parations of  phosphorus,  preferably  the  phosphid  of  zinc  in  eighth  or 
tenth  grain  doses,  three  times  a  day  before  meals,  alternating  it  with  a 
salt  of  arsenic,  such  as  the  arseniate  of  sodium  in  twelfth  of  grain 
doses.  In  rapidly  developing  cases  he  has  found  full  doses  of  ergot 
with  complete  rest  will  sometimes  check  the  progress.  To  relieve  the 
pains  he  has  met  with  the  greatest  success  from  the  use  of  the  extract 
of  cannabis  indica,  injections  of  cocaine  and  acetanilid  alone  or  in 
combination.  Nitrate  of  silver,  alumnium  chloride  or  mercury  seem 
to  him  to  have  never  given  any  beneficial  results  in  ordinary  cases 
while  he  has  seen  marked  injury  done  in  more  than  one  case  by  theuse 
of  strychnine. 

Regarding  Fraenkl's  treatment  Professor  F.  Raymond,  of  Paris,  in 
a  clinique  delivered  at  the  Salpetriere  on  January  17,  1896,  sums  up 
its  value  as  follow;,,  comparing  it  with  suspension: 

Its  only  pretention  is  to  ameliorate  one  of  the  numerous  symptoms 
if  tabes  dorsalis,  the  incoordination,  hence  it  is  inferior  to  suspension. 
It  is  also  inferior  to  it  from  the  fact  that  the  time  required  to  obtain  a 


28 


PEDIATRICS. 


like  result  from  it  is  very  lengthy  (5  to  6  months )  and  requires  a  great 
deal  of  perseverance  on  the  part  of  both  the  patient  and  the  doctor. 
On  the  other  hand  it  is  gentler  and  the  idea  less  terrible  to  the  patient 
than  suspension  and  does  not  present  the  same  dangers.  As  far  as 
therapeutic  results  go  their  value  seem  to  be  about  identical. 

S.  W.  B. 


PEDIATRICS. 

IN  CHARGE  or 

J.  W.  P.  Smithwick,  M.  D.,  LaGrange,  N.  C. 


Infantile  Scurvy.— Dr.  Arthur  M.  Jacobus  (MedicpJ  News,  Jan- 
uary 15,  1898 )  reports  an  interesting  case  of  scurvy  in  an  infant  four- 
teen months  old,  which  was  successfully  treated  in  the  following  man- 
ner: The  baby  had  been  fed  almost  entirely  on  proprietai-y  food  since 
its  weaning  at  the  age  of  five  months.  This  was  entirely  discontinued 
and  the  following  ordered:  ''Robinson's  prepared  barley,  well  cooked 
with  water,  and  as  thick  as  rich  milk,  and  the  best  cow's  milk  that  she 
could  obtain  in  the  city,  unsterililed  or  raw,  in  equal  parts,  with  two 
teaspoonfuls  of  pure  cream,  two  teaspoonfuls  of  lime  water,  and  one- 
half  to  one  teaspoonful  of  the  best  granulated  sugar  at  each  feeding. 
It  was  directed  that  the  child  be  fed  about  once  in  two  to  three  hours, 
dependiHg  upon  the  quantity  she  could  take  and  retain  at  eaeh  feeding. 
At  first  she  could  only  take  about  three  ounces  at  a  feeding,  but  by  the 
nd  of  the  second  week  she  took  as  much  as  five  or  six  ounces,  and 
later,  eight  to  ten  ounces.  After  the  second  week  the  proportion  of 
milk  was  increased  to  two-thirds,  and  barley  or  oatmeal  water  and  the 
rest  of  the  mixture  together  making  one-third.  From  the  first  she  was 
also  given  the  juice  of  two  medium-sized  choice  sv/eet  oranges  each 
day  in  teaspoonful  doses,  with  sugar,  and  as  much  water  then  and 
between  feedings  as  she  desired.  The  mother  was  told  that  she  could 
give  the  baby  the  diluted  sweetened  juice  of  one  lemon  each  day  if  at 
any  time  unable  to  obtain  good  oranges.  The  child  was  also  given 
beef  juice  prepared  as  follows:  I  had  heard  from  some  teacher  that 
beef  juice  should  never  be  allowed  to  become  cold  from  the  preparation 
to  the  feeding,  otherwise  there  would  be  a  chemie  change  injurious  to 
the  juice,  so  that  the  mother  was  told  to  take  a  small  piece  of  "top 
sirloin,"  sear  it  quickly,  first  on  one  and  then  on  the  other  side,  and 
then  to  broil  it  over  a  bed  of  live  coals  until  the  juice  began  to  run 
when  she  was  to  score  it  with  a  hot  knife,  squeeze  it  w^ith  a  hot  lemon 
squeezer  into  a  hot  saucer,  and  add  a  pinch  of  salt  and  serve  with  a 
hot  spoon  as  it  cooled  down  sufficiently  to  be  fed  to  the  baby  without 


•  129 

burning  its  mouth.  The  baby  was  fed  from  two  to  four  teaspoonfuls 
of  beef  juice  freshly  prepared  in  this  manner  twice  each  day.  This 
was  the  entire  treatment. ' ' 

Dr.  Jacobus  opposes  the  use  of  sterilized  milk  except  as  a  tempor- 
ary food  in  cases  of  acute  intestinal  disorders,  and  believes  that  when 
relied  upon  as  the  main  diet  it  will  prove  detrimental  to  the  health  of 
the  infant,  and  particularly  that  it  is  a  causative  factor  in  scurvy. 
He  thinks  the  solution  of  the  difficulty  lies  in  filtei-ed  milk:  obtain  the 
purest  rich  cow's  milk,  carefully  filter  it,  as  directed  by  Seibert. 
dilute  it  freely  and  modify  it,  as  described  by  Jacobi,  Rotch,  and 
others,  by  the  addition  of  water,  cane  sugar,  and  barley  rice,  or  oat- 
meal, and  lime-water  according  to  the  necessities  of  each  particular 
case,  and  a  food  is  obtained  that  will  be  perfectly  satisfactory.  His 
success  in  feeding  cow's  milk  to  childi^en  has  correspondingly  increased 
as  he  has  followed  the  advice  of  Jacobi  in  the  high  or  extreme  dilution 
of  the  milk:  also  that  cane-sugar  instead  of  milk-sugar  be  added  to 
the  milk.  Of  this  Jacobi  gives  twenty  grams  daily,  and  more  during 
constipation. 


OBSTETRICS. 

in  charge  of 

Geo.  Gillett  Thomas,  M.  D.,  R.  l.  Payne.  M.  D. 


Interksting  Obstetrical  Cases.— Dr.  R.  C.  Bankston  reported  to  the 
Jefferson  County  Medical  Society  (Ala.  Med.  &  Surg.  Age)  three  interesting 
cases  in  obstetrical  practice.  The  first  one  was  a  case  of  spontaneous  ver- 
sion. 

He  was  called  to  a  woman  in  labor  and  after  due  preparation  made  an  ex- 
amination and  found  that  the  labor  was  nearing  completion.  A  still  born 
child  was  delivered  without  incident.  After  using  measures  for  resuscitation 
without  effect,  he  tied  the  cord  and  proceded  to  express  the  placenta.  Grasp- 
ing the  uterus  over  the  fundus,  he  realized  that  there  was  another  baby. 
The  placenta  came  promptly,  and  with  it  a  mass  protruded  through  the 
vulva,  which  proved  to  be  a  transparent  bag  of  fluid,  and  within  it  the  hand, 
arm  and  shoulder  of  the  second  child.  He  ruptured  the  membrane  and 
allowed  the  escape  of  a  quantity  of  fluid.  The  next  uterine  contraction 
forced  a  portion  of  the  child  into  view.  After  ineffectual  efforts  to  turn  the 
child  he  anaesthetized  the  patient  and  sent  for  Dr.  Barclay  in  consultation. 
While  awaiting  the  coming  of  the  doctor  he  tried  changing  the  woman's 
position.  As  the  child  lay  with  its  head  to  the  left  side  of  the  mother,  its 
back  to  hers,  he  directed  her  to  turn  on  her  right  side  so  that  the  head  could 
gravitate  from  its  position.  While  waiting  and  watching  for  developments 
she  soon  had  a  very  severe  pain,  and  as  the  pain  ceased   he   found  that  he 


J  OBSTETRICS. 

could  push  up  the  protruding  parts  and  proceeded  to  do  so.  He  carried  the 
side  and  shoulder  up  and  grasped  the  forearm  to  push  it  gently.  Turning 
to  explain  the  condition  to  Dr.  Barclay,  who  had  just  entered  the  room,  but 
retaining  his  grasp  upon  the  arm  of  the  child,  the  woman  cried  out  with 
another  pain,  and  suddenly  the  hand  of  the  child  was  drawn  upward  out  of 
his  grasp  and  the  breast  presented,  delivery  taking  place  promptly  without 
further  incident,  giving  him  an  opportunity  of  experiencing  his  first  case  of 
spontaneous  version. 

Dr.  Bankston  reported  another  case  of  interest  in  a  young  white  girl,  age 
14,  whom  he  was  called  to  attend.  She  was  having  pains  when  he  entered 
the  room  and  upon  examination  he  found  a  firm  mass  presenting  through 
the  cervix,  which  he  thought  was  one  of  the  buttocks.  Labor  progressed 
slowly.  As  the  night  wore  away,  becoming  impatient  and  tired,  he  gave  her 
chloroform  during  the  early  hours  of  morning  and  attempted  to  grasp  a  foot 
to  bring  it  down.  To  his  astonishment  he  could  not  find  one.  Having 
thoroughly  anaesthetized  his  patient,  he  pushed  up  the  presenting  part  and 
searched  and  found  the  feet,  which  he  brought  down  and  delivered  the 
patient  of  a  small,  premature  child  of  about  eight  months  fceiation.  Upon 
inspection  he  found  that  the  presenting  part  which  he  thought  was  a  buttock 
was  the  left  breast.  The  head  and  buttocks  were  bent  backward  and  the 
chest  presented.  His  conclusion  derived  from  the  case  was  where  the  posi- 
tion cannot  be  positively  determined,  do  not  temporize  long,  but  anaesthetize 
the  patient  and  deliver  promptly. 

He  reported  another  case  in  which  he  was  called  in  consultation.  The 
attending  physician  informed  him  that  he  had  a  severe  case  of  uterine  hem- 
orrhage in  a  woman  aged  about  45,  whom  he  had  operated  on  some  time  since 
for  cancer  of  the  cervix;  that  portion  having  been  removed.  The  doctor  said 
the  liemorrhage  wes  due  to  a  recurrence  of  the  old  trouble.  Dr.  Bankston 
said  from  the  history  he  concurred  in  the  attending  physician's  view  of  the 
case,  and  thought  with  him  that  curettage  and  hot  douches  would  benefit 
her.  Having  completed  preparation,  the  patient  was  anaesthetized  and  the 
attending  physician  prepared  to  curette.  As  he  divulsed  the  cervix  a  bag 
of  fluid  protruded  and  this  filled  the  vagina.  Dr.  Bankston  remarked  to  him- 
that  it  looked  decidedly  amniotic.  He  ruptured  the  bag  and  following  the 
discharge  of  the  fluid  came  a  three  months'  foetus.  The  efforts  of  the  woman 
to  bring  on  her  flow  had  caused  the  hemorrhage.  Several  weeks  had  elapsed 
since  curettage  was  done  for  remeval  of  the  placenta.  The  patient  had  re- 
mained in  apparent'good  health,  with  no  symptoms  of  disease.  Dr.  Bank- 
ston had  never  seen  any  statistics  on  conception  after  amputation,  and  this 
was  the  only  case  he  had  ever  heard  of.  He  thought  it  was  very  rare  and 
unusual. 


Whem  writing  to  advertisers  please  mention  this  Journal. 


MISCELLANEOUS. 


Interna I'lONAL  Lei'rosy  Conference. — The  secretaries  of  the  Conference 
in  presenting  the  genera!  conclusions  arrived  at  say:  As  might  be  expected, 
a  considerable  portion  of  the  discussion  has  related  to  the  bacillus  Leprae, 
which  the  Conference  accepts  as  the  Virus  of  Leprosj^,  and  which  for  upwards 
of  25  years  has  been  known  to  the  scientific  world  through  the  important 
discovery  of  Hansen  and  the  able  investigations  of  Neisser. 

The  conditions  under  vvhich  the  bacillus  grows  and  develops  are  still 
unknown,  as  well  as  the  way  of  its  invasion  into  the  human  system;  but 
from  the  discussions  of  the  Conference,  it  seems  probable  that  an  unanimity 
of  opinion  will  soon  prevail  in  reference  to  its  modes  of  subsequent  dissem- 
ination within  the  human  body. 

Very  interesting  observations  have  been  brought  forward  in  connection 
with  the  elimination  of  the  bacilli  in  large  quantities  by  means  of  the  skin 
and  the  nasal  and  buccal  mucous  membranes  of  lepers;  it  is  desired  that 
such  observations  be  confirmed  where  opportunities  occur. 

The  question  is  of  very  great  importance  to  those  who  are  entrusted  with 
the  care  of  the  public  health,  as  leprosy  is  now  acknowledged  to  be  a  con- 
tagious disease. 

Every  leper  is  a  danger  to  his  surrounding,  the  danger  varying  with  the 
nature  and  extent  of  his  relations  therewith,  and  also  with  the  sanitary  con- 
ditions under  which  he  lives. 

Although  among  the  lower  classes,  every  leper  is  especially  dangerous  to 
his  family  and  fellow  workers,  cases  of  leprosy  frequently  appear  in  the 
higher  social  circles. 

The  theory  of  heredity  of  leprosy  is  now  further  shown  to  have  lost 
ground,  in  comparison  with  the  at  present  generally  accepted  theory  of  its 
contagiousness. 

The  treatment  of  leprosy  has  only  had  palliative  results  up  to  the  present 
time. 

Serum  therapy  has  so  far  been  unsuccessful. 

In  view  of  the  virtual  incurability  of  leprosy  and  the  serious  and  detri- 
mental effects  which  its  existence  in  a  community  causes,  and  considering 
the  good  results  which  have  followed  the  adpotion  of  legal  measures  of  iso- 
lation in  Norway,  the  Leprosy  Conference,  as  a  logical  issue  of  the  theory 
that  the  disease  is  contagious,  has  adopted  the  following  resolution  proposed 
by  Dr.  Hansen  and  amended  by  Dr.  Besnier. 

1.  In  such  countries,  where  leprosy  forms  foci  or  has  a  great  extension, 
we  have  in  isolation  the  best  means  of  preventing  the  spread  of  the  disease. 

2.  The  system  of  obligatory  notification,  of  observation  and  isolation  as 
carried  out  in  Norway,  is  recommended  to  all  nations  with  local  self-govern- 
ment and  a  sufficient  number  of  physicians.     [Health  officers.] 

3.  It  should  be  left  to  the  legal  authorities  after  consultation  with  the  med- 
ical authorities  to  take  such  measures  as  are  applicable  to  the  special  social 
conditions  of  the  districts. 


J  ^2  NOTES    AND  ITEMS. 

Practical  Hints  in  the  Examination  of  the  Blood. — Dr.  Henry  HeiTnar> 
read  a  paper  with  this  title  before  the  Medical  Society  of  the  County  of  New 
York  (Med.  Record).  Speaking  of  the  examination  of  the  blood  for  the  ma- 
larial Plasmodium,  he  said  ihat  the  microscopist  must  carefully  distinguish 
between  nucleated  cells,  degenerated  corpuscles,  and  fungi  developing  in 
the  methylene  blue.  The  special  distinguishing'  feature  was  the  presence  of 
the  characteristic  brown  pigment.  The  best  stain  for  parasites  in  the  blood 
such  as  the  malarial  plasmodium  was  the  double  methylene  blue  and  eosin. 
Incidentally  he  mentioned  that  the  malaria  observed  in  New  York  City  and 
its  immediate  vicinity  was  nearly  always  of  the  tertian  type.  Blood  smears 
might  be  fixed  at  once  by  formalin,  or  the  fixing  process  might  be  postponed 
for  some  time.  As  a  rule,  the  plasmodia  were  found  in  the  red  cells,  stained 
a  light  bluish  color,  and  had  a  form  varying  with  the  stage  of  the  disease. 
In  chronic  malarial  poisoning  the  plasmodium  was  rarely  found. 


Motes  anb  Items. 


Dr.  S.    N.  Harrell  has  removed  to  Tarl)oro,  N.  C, 

"Doc" — The  editor  of  the  A^o.  A//ier.  Jour,  of  Diagnosis  and 
Praciiee  was  accosted  with  the  question  "Are  you  an  allopath, 
Doc?"  He  let  it  be  distinctly  understood  that  he  belongs  to  the 
"old  school,"  known  as  "regular."  In  regard  to  "Doc"  he  says 
"Better  call  me  a  thief,  a  frasd  or  a  race-horse  tout,  than  the 
vile  name  of  "Doc." 

North  American  Journal  of  Diagnosis  and  Practice. — A  new  jour- 
nal published  in  St.  Louis  has  adopted  the  above  title.  The 
initial  number  is  dated  January  1898  and  the  editors  are  C.  H. 
Powell,  M.D.,  J.  G.  Ehrhardt,  M.  D.,  and  A.    R.  Kilffer,  M.  D 

Practice  of  Medicine  Defined.— Judge  Thompson  of  Ken- 
tucky, in  sentencing  an  asteopath  thus  defined  the  practice  of 
medicine,  "Any  person  who,  for  compensation,  professes  to 
apply  any  science  which  relates  to  the  prevention,  cure  or  allevi- 
ation of  the  diseases  of  the  human  body,  is  practicing  medicine 
within  the  meaning  of  the  statue.'' 

Excision  of  the  Stomach. — Two  very  ambitious  American 
surgeons  living  respectively  in  St.  Louis  and  Chicago,  prompted 


NOTES    AND  ITEMS.  1,5 

by  the  favorable  results  obtained  by  a  Swiss  surgeon,  Dr. 
Schlatter,  who  successfully  removed  the  stomach  and  united  the 
duodenum  and  oesophagus  in  a  case  of  malignant  disease,  have 
ventured  upon  this  rash  procedure  with  the  result  that  the  pa- 
tient in  each  case  died  promptly.  Did  these  surgeons  before 
undertaking  those  operations,  ask  themselves  if  they  would  al- 
low the  operation  to  be  performed  upon  one  who  was  very  dear 
to  them,  though  suffering  with  the  same  disease  as  were  their 
patients?  If  not  they  were  guilty  of  grossly  improper  conduct 
and  do  not  deserve  to  be  classed  among  the  reputable  mem- 
bers of  their  profession. 

The  Universal  Medical  Journal,  has  come  out  new  and  attrac- 
tive dress,  with  double  column  pages,  and  a  change  of  title  to 
The  M0tithly  Cyclopczdia  of  Practical  Medicine  and  Univereal  Medical 
Journal.  It  is  ably  edited  by  Dr.  Chas.  E.  Sajous,  and  pub- 
lished by  the  F.  A.  Davis  Co.,   Philadelphia. 

Editor  of  the  British  Medical  Journal.  Dr.  Dawson  Williams 
has  been  unanimously  elected  to  fill  the  position  made  vacant 
by  the  recent  death  of  Mr.  Ernest  Hart.  Dr.  Williams  has  been 
the  assistant  editor  for  the  past  17  years. 

We  take  pleasure  in  announcing  that  we  have  been  able  to  add 
to  our  list  of  Department  Editors,  Dr.  J.  W.  P.  Smithwick,who 
will  take  charge  of  the  Department  of  Paediatrics.  Dr.  Smith- 
wick  is  the  compiler  of  the  latest  Ornithology  of  North  Caro- 
lina, which  has  been  published  by  the  Agricultural  Department 
of  the  State.      He  has  recently  removed  to  La  Grange,  N.  C. 

A  Practical  Patient. — A  physician  calling  one  day  on  one 
of  his  patients  who  was  afflicted  with  the  gout,  found,  to  his 
surprise,  the  disease  had  gone,  and  the  patient  rejoicing  in  his 
recovery  over  a  bottle  of  wine.  "Come  along, doctor,"  exclaimed 
the  valetudinarian,  "you  are  just  in  time  to  taste  this  bottle  of 
Madeira;  it  is  the  first  of  a  pipe  that  has  just  been  broached. 
"Ah!"  replied  the  doctor,  "these  pipes  of  Madeira  will  never 
do;  they  are  the  cause  of  all  your   suffering."      Well,    then,   re- 


-  ,  NOTES  AND  ITEMS. 

joined  the  gay  incurable,  "fill  up  your  glass,  for  now  that  we 
have  found  out  the  cause,  the  sooner  we  get  rid  of  it  the  better." 
—  The  Sanitarian. 

Besieging  a  Dispensary. — Some  michievous  liar  recently  set 
afloat  a  story  that  two  negro  children  had  been  kidnapped  by 
the  physicians  of  the  St.  James  Dispensary  in  Savanah,  and 
carried  into  the  building  and  killed.  The  story  soon  spread 
among  the  colored  population  and  was  confirmed  apparently  by 
some  school  children,  who  said  they  had  climbed  into  a  tree 
which  grows  near  one  of  the  dispensary  windows,  and  had  seen 
the  bodies  of  the  two  children  on  a  table,  and  that  white  men 
were  standing  around  them  cutting  them  up.  A  mob  of  negroes 
soon  gathered  in  front  ot  the  dispensary  building,  and  were  dis- 
persed by  the  police  only  after  several  of  the  ringleaders  had 
been  arrested.  The  excitement  continued  for  several  days,  and 
crowds  of  excited  colored  men  and  women  assembled  repeatedly 
in  front  of  the  building.  The  colored  teachers  in  the  schools 
and  the  pastors  of  the  colored  churches  have  been  asked  to  use 
their  influence  to  disabuse  the  minds  of  the  negroes  of  their  be- 
lief in  the  vivisection  practices  of  the  dispensary  doctors.  It 
will  probably  be  a  long  time  before  a  pickaninny  ventures  to 
pass  the  door  of  St.  James  Dispensary  after  nightfall. — Medical 
Record. 

Foot-Ball.  —  The  I?isurance  Press  gives  the  following  statistics 
of  casualties  in  the  leading  schools  and  colleges  within  the 
United  States  covering  the  last  of  the  season  for  1896,  and  the 
first  of  the  season  just  closed,  namely:  number  of  dead,  9;  per- 
manently injured,  16;  seriously  injured,  120;  minor  casualties, 
130.  This  table,  it  will  be  noted,  refers  to  this  country  only, 
and  covers  only  a  portion  of  two  seasons.  For  this  time  the 
total  casualties  of  all  descriptions  amount  to  275.  What  would 
be  the  sum  for  the  full  season  in  all  countries? 

As  a  means  of  advertising  a  university  the  games  may  be  of  great 
value,  but  they  serve  no  purpose  in  developing  the  bodies  of  the 
great  bulk  of  students  attending  our  colleges,  since  it  is  only 
the  already  developed  men  who  are  sought  after  to  engage  in 
this  sport. 


BEADING  NOTICES.  t^r 

The  liard  working  student  whose  brain  has  probably  developed 
somewhat  at  the  expense  of  his  body,  the  one  who  requires  phy- 
sical exercise,  must  be  an  onlooker  at  the  wild  plunging  of  his 
brother  student,  who  is  brought  to  the  university  (foot-ball  team) 
oftimes  because  of  his  overdeveloped  legs  and  brawny  arms 
rather  than  his  brilliant  intellect. — Med. and  Surg.  Bull. 


NECROLOGY. 


Dr.  S.  A.  Rogers,  at  Memphis,  Tennessee,  January  7, 1898.  Dr. 
Rogers  was  professor  of  anatomy  in  the  Memphis  Medical  Col- 
lege. Ae  was  shot  in  the  back  by  a  woman  who  immediately 
sent  a  bullet  into  her  own  heart. 

Dr.  Theophilus  Parvin,  aged  60  years,  at  Philadelphia,  Janu- 
ary 29,  1898.  He  was  elected  in  1883  professor  of  obstetrics  in 
the  Jefferson  Medical  College,  of  Philadelphia. 

Dr.  Jules  Emile  Pean,  in  Paris  January  30,  1898. 


IReaMna  flotlcce. 


An  Interesting  Case  of  Anaemia. — MissG.  H. — ,Avondale, 
O.  ;  age  24;  American;  anaemia.  First  seen  November  6,  1897. 
This  case  had  been  under  treatment  by  various  physicians,  for 
two  years,  but  the  patient  got  no  permanent  relief.  Casually 
observing  the  patient,  anyone  might  justly  have  exclaimed, 
What  a  perfectly  healthy  specimen  you  are!  The  only  symp- 
toms apparent  were  that  at  times  she  became  exhausted  after 
some  trifling  exercise, and  at  other  times  lapsed  into  a  faint  with- 
out apparent  cause;  nor  were  these  attacks  accompanied  with 
hysteria:  she  merely  complained  of  being  weak  and  tired.  The 
attacks  of  fainting  were  periodical,  with  at  times  complete  un- 
consciousness; at  other  times  were  such  as  might  be  called  k 
petit mal.  The  patient  said,  however,  she  had  noticed  that  her 
hair  seemed  to  have  grown  a  bit  lighter  within  the  last  three  or 
four  months. 


1^6  HEADING   ]SrOTICES. 

The  blood  was  about  normal  in  color  to  the  eye;  microscopically 
hovvexer,  the  picture  was  decidely  abnormal.  One  cubic  centi- 
meter of  blood  showed  but  i,  500,000  red  corpuscles,  with  a  de- 
cided overplus  of  white  cells.  The  red  cells  were  in  the  various 
stages  of  disintegration  and  paralysis.  The  haemaglobin  was 
not  more  tlian  twenty  per  cent,  of  the  normal  quantity.  In^ 
the  specimen  of  blood  from  the  hand  of  the  patient,  the  red 
corpuscles  were  absolutely  devoid  of  coloi  ;  this  being  an  unusal 
picture,  and  indicating  in  my  mind,  the  initial  cause,  if  not  a 
beginning,  of  fatty  degeneration:  a  subject  too  extensive  to  be 
discussed  within  present  limits. 

It  was  accordingly  determined  to  put  patient  on  the  following 
simple  course  treatment.  Night  and  morning  she  was  massaged 
with  alcohol,  and  instructed  to  take  plenty  of  outdoor  exercise;; 
at  the  same  time  observing  great  care  in  dressing  to  avoid  catch- 
ing cold.  From  the  first,  the  patient  thoroughly  enjoyed  the 
taking  of  bovinine,  and  consequently  a  large  quantity  was  im- 
mediately prescribed:  a  wineglassful  every  three  hours,  during 
the  day,  in  milk.  Within  the  first  forty-eighthours,  the  patient 
felt  very  much  improved;  remarking,  "Why,  doctor,  do  you 
know,  I  feel  stronger  and  brighter  already!  I  know  this  treat- 
ment is  doing  me  much  good."  The  treatment  was  continued 
up  to  the  22d  of  November  y  when  a  microscopic  examination  of 
the  blood  showed  that  the  quantity  of  haemaglobin  was  increased 
to  fully  half  the  normal.  The  number  of  red  corpuscles  had 
also  increased  considerably.  Since  November  the  14th  there 
had  been  no  fainting  spells.  In  fact,  the  patient  said  she  hadn't 
'  'an  ache  or  pain.  "  The  quantity  of  bovin  ine  was  now  increased 
to  a  wineglassful  five  times  a  day.  November  30th,  microscopic 
examination  of  the  blood  showed  the  red  corpuscles  to  be  already 
quite  normal  in  quantity.  The  haemaglobin  lacked  but  about 
one-eight  of  the  normal  standard.  From  the  14th  to  this  date, 
the  patient  had  continued  free  from  attacks  of  any  kind.  She 
will  continue  under  observation  for  fully  five  weeks  longer,and 
reports  of  the  case  may  be  made  from  time  to  time;  certainly, 
in  case  of  less  favorable  appearances. — Records  Sound  View  Hos- 
pital, Stanford,  Conn. 


DOCTOR: — Ynur  lidsary  is  not  complet  without  the  Hyp- 
notic Magazine.  Cost  of  this  handsome  monthly,  including 
premium  book  on  Suggestive  Therapeutics  is  only  one  dollar 
($1.00)  a  year. 

THE  PSYCHIC  PUBLISHING  CO., 
56  5th  Avenue,  Chicago. 


f 


Parturition.— Aletris  Cordial  (Rio). 
[?iven  in  teaspoonful  doses  every  hour 

|3r  two  after  Parturition,  is  the  best 
sigent  to  prevent  after-pains  and  hem- 
3rrhage.  By  its  direct  tonic  action  on 
;he  uterus,  it  expels  blood  clots,  closes 
he  uterine  sinuses,  causes  the  womb 
t|o  contract,  and  prevents  subinvolu- 
tion. In  severe  cases,  it  can  be  com- 
bined with  ergot  in  the  proportion  of 
)ne  ounce  of  fluid  Ext.  Ergot  to  three 
Dunces  Aletris  Cordial  (Rio).  It  is  the 
Bxperience  of  eminent  practitioners,  in 
all  cases  where  ergot  is  indicated,  that 
its  action  is  rendered  much  more  effica- 
cious by  combining  it  with  Aletris  Cor- 
dial, Rio,  in  the  proportions  above 
stated. 

A   sample   bottle   will  be  sent   free  to  any  physician  who  desires  to 
test  it,  if  he  will  pay  the  express  charges. 

RIO  CHEMICAL  CO.,  St.  Lottto,  Mo.,  U.  S.  A. 


Parturition.— Aletris  Cordial  (Rio), 
given  in  teaspoonful  doses  every  hour 
or  two  after  Parturition,  is  the  best 
agent  to  prevent  after-pains  and  hem- 
orrhage. By  its  direct  tonic  action  on 
the  uterus,  it  expels  blood  clots,  closes 
the  uterine  sinuses,  causes  the  woml 
to  contract,  and  prevents  subinvolu-j 
tion.  In  severe  cases,  it  can  be  com- 
bined with  ergot  in  the  proportion  oj 
one  ounce  of  fluid  Ext.  Ergot  to  three^ 
ounces  Aletris  Cordial  (Rio).  It  is  the 
experience  of  eminent  practitioners,  in 
all  cases  where  ergot  is  indicated,  that 
its  action  is  rendered  much  more  effica- 
cious by  combining  it  with  Aletris  Cor- 
dial, Rio,  in  the  proportions  above 
stated, 

A  sample  bottle  will  be  sent  free  to  any  physician  who  desiresi 
test  it,  if  he  will  pay  the  express  charges. 

RIO  CHBMICAL  CO.,  St.  Louis,  M«.,  U.  S.  A. 


NORTH  CAROLINA 

MEDICAL  JOURNAL 


A  SEMi-MONTHLY  JOURNAL  OF  MEDICINE  AND 
SURGERY. 

Vol.  XLI.  Wilmington,   March  5,    1898.  No.    5. 


Original  Communicatlone* 


CHRONIC  LARYNGITIS— SOME  O^  ITS  CHIEF 
CAUSES  AND  RESULTS.* 
John  F.  Woodward,  M.  D.,   Norfolk,  Va. 


THE  subject  of  this  paper,  second  to  none  in  importance, 
wherein  the  air  passages  are  under  discussion, has  not  been 
discussed  of  late  with  that  interest  and  thoroughness, which 
characterizes  usually  the  investigations  of  the  throat  and  nose 
specialist.  While  brochure  and  caption  specializing  the  influence 
of  nasal  and  pharyngeal  stenosis  or  obstruction,  have  appeared, 
yet  their  ultimate  design  seems  to  be  to  impress  us  with  the  re- 
mote possibilities,  rather  than  open  our  eyes  to  the  omnipresent 
every  day  facts.  I  again  insist  that  we  need  more  bedside  and 
office  symptoms  than  we  do  meaningless  theories  and  distorted 
hypotheses. 

With  the  microscope,  v/ell  equipped  laboratories  and  the  X- 
ray,  medical  reasearch  and  investigation  are  the  legitimate 
property  of  every  scientific  mind.  Why  not,  therefore,  feel  it 
our  special  privilege  to  add  something  every  year  to  a  cause  that 
is  as  broad  and  generous  as  time,  and  as  lasting  as  the  world 
itself.  Every  medical  topic,  though  written  upon  and  rehashed 
by  men  of  known  and  unknown  talents,  contains  at  some  time 
features  new  and  interesting  to  all  of  us,  did  we  but  make  them 
a  part  of  our  library. 
*Read  before  the  Seaboard  Medical  Association,  January  21,  1898. 


Q  WOODWARD.— CHRONIC  LARYNGITIS,  ETC. 

Thus,  I  present  to  you  to-day  no  new  theme,  no  new  type  of 
disease,  but  a  few  causes  and  results  which  follow  each  other 
so  closely  that  their  conspicuous  absence,  or  mere  mention  in 
text  books  makes  thena  of  no  uncertain  interest. 

You  are  no  doubt  familiar  with  the  important  discussions  of 
to-day — "How  to  keep  the  side-walks  clean"  "Can  we  all  ride 
bicycles",  subjects  that  disturb  not  the  minds  of  our  early  fathers 
in  medicine,  yet,  today  are  of  vital  importance  as  things  good 
or  evil,  to  hamper  or  encourage  an  ever  changing  people  in  the 
pursuit  of  health  or  happiness. 

You  have  noticed,  in  public  halls,  public  conveyances,  stores 
and  many  other  places,  cuspidors  here  and  there.  They  are  not 
simply  for  tobacco  chewers.  We  are  a  race  of  spittcrs  and 
"hawkers."  Did  you  ever  stop  and  think  why  it  is  that  two 
thirds  of  our  people  have  to  currette  their  throats  every  ten  or 
fifteen  minutes  and  then  lubricate  the  congested  surface  with 
saliva?  Are  not  our  social  chats  constantly  being  interrupted 
by  "hawks"  and  "hemms"  and  the  clergy  and  public  speakers 
generally  resorting  to  cough  lozengers  and  lubricants?  Are 
not  many  of  our  best  vocalists  forcing  there  voices  at  the  ex- 
pense of  chest  and  vocal  cords?  There  is  a  cause  for  this  com- 
mon human  distemper  outside  of  the  habit  feature.  It  is  chronic 
laryngitis  the  subject  of  this  paper. 

Chronic  laryngitis  is  a  chronic  inflammation  of  the  mucous 
membrane  of  the  larynx,  very  common,  and  most  frequently 
seen  in  adults;  generally  secondary  to  some  acute  inflammation, 
the  remote  expression  of  some  primary  laryngeal  irritation  whose 
persistence  is  but  the  first  fruit  of  an  endless  chain  of  conditions 
the  logical  result  of  an  abnormal  state  of  the  upper  air  passages. 
As  the  wind  blows  from  land  or  water,  so  is  the  climate  of  that 
locality.  Laryngitis  is  insidious  in  its  onset  and  indefinite  in 
Its  limitations;  characterized  by  hoarseness,  tendency  to  clear 
the  throat,  and  constant  tickling  as  if  som.e  foreign  body  were 
in  the  way,  unexpected  expulsion  of  tough  balls  of  mucus,  slug- 
gish movement  of  the  vocal  cords,  with  occasionally  unilateral 
paresis,  fatigue  of  the  throat  during  and  after  talking  or  sing- 
ing, voice  worse  in  the  morning  but  better  after  using  it,  more 
or  less  redness  of  membranes  with  mild  or  decided  swelling  of 
parts,  seldom  ulcers,  pain  or  fever,  and  in  many  cases  an  irri- 
tant cough. 


WOODWERD.— CHRONIC  LARYMGITIS,    ETC. 


139 


I  shall  limit  myself  to  the  causes  and  results,  as  the  pathology 
symptoms  are  thoroughly  discussed  by  the  different  authors  on 
this  subject.  Having  questioned  my  patients  very  closely  in  the 
last  few  years,  as  to  when  they  first  began  to  notice  that  their 
throats  were  becoming  affected,  none  of  them  could  give  a  de- 
finite date,  but  referred  to  a  period  when  they  had  head  colds 
and  stuffy  sensations  in  their  heads,  and  later  on  a  conscious- 
ness of  throat  trouble,  a  sense  of  fullness  and  tickling  with  a 
desire  co  swallow  or  clear  away  something,  or  get  rid  of  a  drip- 
ping from  the  vault  of  the  pharynx.  Many  of  them  followed 
this  sequence — nose  trouble,  fullness  |in  the  ear  or  cars,  and 
then  irritation  of  the  larynx.  In  some  cases  there  was  a  sense  of 
dryness  instead  of  hyper-secretions.  They  could  all  recall  a 
time  when  they  had  had  colds  and  nose  trouble.  There  are 
many  inherited  tendencies  and  physical  conditions  that  render 
acute  laryngitis  liable  to  take  on  a  chronic  state,  yet,  the  recu- 
perative power  of  the  larnyx  is  very  active  unless  aggravated  > 
by  morbid  environments. 

Lately,  I  have  had  som,i  very  interesting  cases  that  have  so 
impressed  me,  that  I  feel  as  if  a  healthy  upper  air-passage  would 
generally  mean  a  healthy  larynx. 

Etiology  as  commonly  noted  in  text-books  consists  of  phthisis, 
syphilis,  cancer,  lupus,  polypoid  growths,  alcohol,  tobacco,  the 
exanthemata,  inhalations  of  irritant  particles  of  dust,  metal, 
drugs,  over  use  of  the  voice,  and  nasal  disorders.  The  latter 
merely  referred  to  without  saying  much  to  qualify  their  promi- 
nence as  factors  in  producing  or  abetting  a  chronic  state  of  the 
larynx.  On  the  contrary,  I  look  upon  disorders  of  the  nose  and 
the  naso-pharynx,  as  the  chief  and  primal  causes,  and  when 
they  do  not  originate  tliey  stimulate  this  condition  of  the  larynx. 
Tobacco  smoking,  except  cigarrette  inhaling,  which  I  most 
heartily  condemn,  and  alcohol  play  no  special  part  in  these  cases 
outside  of  the  fact  that  an  excess  may  irritate  and  aggravate  a 
throat  that  is  already  diseased,  and  lessen  to  some  extent  the 
chances  of  a  complete  cure.  Irritant  drugs  and  metals  will 
irritate  the  nose  and  naso-pharynx  as  well.  The  other  causes 
referred  to  seldom  appear  as  a  cause  of  a  true  chronic  laryngitis 
in  my  practice. 

The  following  cases  will  illustrate: 


J  .Q  WOODWARD.-tniRONIC  LARYNGITIS,    ETC. 

Case  1.— Mr.  W.  A.,  aet.  30,  consulted  me  in  the  early  part  of  1897, 
complaining  of  constant  worry  about  his  throat.  Tendency  to  hawk 
and  clear  the  throat,  and  at  times  when  coug-hing  small  tough  particles 
would  lly  from  his  mouth  in  the  most  unexpected  manner.  He  referred 
to  a  fulness  in  the  ears  when  his  throat  was  bad,  aud  sitting  m  a  draft 
would  change  the  tone  of  his  voice  in  five  minutes;  talking  and  sing- 
ing make  his  larynx  feel  tired  aud  full,  voice  soft  at  times  and  then 
very  harsh,  any  irritant  causes  him  discomfort,  and  changes  in  tem- 
perature produce  a  profound  impression  upon  his  voice,  while  his 
pharynx  and  naso-pharynx  felt  stuffy  and  full  of  mucus.  He  has 
hypertrophy  of  both  inferior  turbinates  and  septal  spur  on  the  left. 
His  larynx  was  red  and  slightly  tumefied,  with  sluggish  condition  of 
all  of  the  membranes.  Treatment  has  almost  entirely  relieved  him. 
Case.  2. — Mr.  A.,  came  to  see  me  in  the  summer  of  1897  to  have  a  grain 
of  corn  removed  from  his  throat.  He  gave  such  a  clea^r  history  of 
having  swallowed  the  coi*n  and  then  the  sudden  onset  of  the  dyspnoea 
that  I  felt  pretty  sure  I  had  a  case  of  foreign  body  in  the  lai^ynx.  Ex- 
amination showed  on  the  contrary,  that  he  had  a  chronic  laryngitis 
with  enlargement  of  the  membranes.  The  swelling  was  so  great  that 
only  the  anterior  portion  of  the  left  vocal  cord  could  be  seen,  covered 
with  a  whitish  mucus.  He  was  soon  able  to  use  his  voice  and  the  grain 
of  corn  was  never  found.  This  case  had  every  symptom  of  a  foreign 
body  in  the  larynx. 

Case  3. — C.  W.,  aet.  6.,  was  brought  to  me  last  August  with  the  re- 
port that  he  had  svy allowed  a  water-melon  seed.  The  spasmodic  dys- 
pnoea and  aphonia  with  other  symptoms  indicated  just  what  his  doctor 
had  diagnosed,  a  seed  lodged  in  the  trachea.  On  examination  I  found 
no  seed  but  a  very  red  and  congested  larynx.  As  he  was  so  comfort- 
able at  times  I  let  him  alone  with  some  simple  treatment.  About  the 
third  day  I  was  hum-iedly  called  but  found  him  sleeping.  I  took  his 
temperature,  103  F. ,  and  then  put  him  on  some  fever  treatment.  In  a 
few  days  he  was  all  right,  except  his  throat  was  irritable  for  some  time 
after. 

Case  4.— A.  G.,  came  to  me  a  few  days  ago  to  have  a  pin  removed 
from  her  throat,  said  she  hau  a  pin  is  her  mouth  when  she  fell  asleep, 
and  when  she  awoke  she  felt  the  pain.  I  found  no  pin  but  tonsillitis 
and  chronic  laryngitis.  The  larynx  was  congested  and  the  patient 
hoarse.     Whitish  threads  of  mucus  hung  from  the  vault  of  the  pharynx. 

Case  5.— C.  M.,  aet.  35,  consulted  me  about  nine  months  ago  about 
loss  of  voice  and  asthma.  Septum  bent  towards  the  left  with  adhesions, 
naso-pharyngitis  with  follicular  pharyngitis,  chronic  laryngitis  with 
enlargements  on  the  right  side  that  looked  like  malignant  tumors. 
Right  vocal  cord  almost  motionless,  approximation  impossible,  cords 
swollen  and  covered  with  mucus.  He  cannot  make  high  or  low  notes. 
His  asthma  has  left  him  but  the  treatment  so  far  has  not  entirely  re- 
stored his  voice. 

Case  6.— Mr.  S.,  aet.  30,  has  had  voice  fatigue  and  horseness  for 


WOODWARD.-CURONIC  LARYNGITIS,    ETC.  j  .  j 

some  time.  He  is  a  public  speaker,  has  follicular  pharyngitis  and  nose 
trouble,  slight  nasal  catari-h.  I  found  chronic  congestion  and  enlarge- 
ment about  the  laryngeal  membranes.  Voice  entirely  gone,  could  only 
whisper,  left  vocal  cord  sluggish  and  the  arytenoids  did  not  approxi- 
mate on  attempt  at  phonation.  Treatment  of  nose  and  throat  relieved 
him  in  six  weeks. 

Case  7.— Mr.  H.,  aet.  25,  clerk,  had  almost  complete  stenosis  of  left 
nostril  with  follicular  pharyngitis  and  constant  dripping  in  the  throat. 
Chronic  laryngitis  was  the  result,  and  in  three  months  he  had  lost  his 
voice.  His  larynx  was  slightly  congested  and  rough  looking,  with  a 
tenacious  mucus  hanging  to  the  cords.  The  nose  was  operated  upon 
and  the  air  space  made  almost  perfect  and  his  pharynx  and  larynx 
treated  and  in  five  weeks  he  could  talk  as  well  as  ever. 

Case  8.— Mr.  M.,  aet.  29,  N.  Y,,  consulted  me  in  November  1897, 
about  his  tonsils.  I  found  him  with  chronic  tonsillitis  and  unable  to 
talk  above  a  whisper.  He  said  he  had  had  throat  and  nose  trouble  for 
several  years,  but  had  been  without  his  voice  for  only  six  months  and 
had  been  told  by  good  specialists  that  he  would  not  recover  it  again 
soon.  After  treating  his  nose  and  tonsils  I  put  him  on  treatment  for 
his  voice.  I  did  not  see  him  again  but  one  month  later  received  a 
letter  from  him  saying  he  was  perfectly  well  and  could  talk  as  well  as 
ever.  There  was  no  paralysis  in  his  case,  but  the  same  sluggish  con- 
dition described  above. 

These  cases  are  interesting  to  us  in  many  ways,  especially 
since  they  point  out  a  condition  of  the  vocal  cords  that  is  me- 
chanical to  a  great  extent  and  amenable  to  treatment,  rather 
than  a  true  paralysis.  It  also  gives  us  an  insight  into  many  of 
the  ills  that  present  themselves  in  voice  culture,  as  vi^cll  as  a 
solution  of  the  question  in  many  cases  of  suspected  foreign 
bodies  in  the  larynx  and  in  the  trachea. 

It  is  my  aim  in  further  discussing  this  subject  to  add  another 
voice  to  the  already  large  list  of  believers  that  nasal  and  naso- 
pharyngeal disorders  by  direct,  as  well  as  by  reflex  and  mechani- 
cal interference,  abet  and  foster  a  chronic  state  of  the  larynx. 
There  is  a  combination  of  effects  direct  and  reflex  exhibited  in 
disorders  of  the  ear,  nose  and  throat,depending  upon  a  peculiar 
sympathy,  wherein  what  seems  to  be  a  single  result  is  the  totality 
of  a  concerted  action  of  the  three  factors.  Kurt,  recognizing 
this  sympathy,  put  sedatives  on  the  conjunctiva  to  control  whoop- 
ing cough,  and  on  the  mucous  membrane  of  the  nose  to  stop 
laryngeal  spasm.  Is  it  strange  that  the  larynx,  delicate  and 
easily  inflamed,   placed  as  it  is  at  the    apexf  of    the    air  funnel 


WOODWARD.-CHRONIC  LARYNGITIS,    ETC. 
142 

should  leel,  and  respond  to  the    irregularities  of    the   upper  air 
passages? 

Given,  then,  a  larynx  with  its  delicate  mucous  membrane.and 
its  full  supply  of  squamous  epithelium  over  the  arytenoid  and 
vocal  bands,  closely  allied  to  cutaneous  substance  (Virchow) 
with  a  few  glands,  (in  the  arytenoid  and  vocal  bands)  aad  full 
supply  of  blood  vessels,  a  ready  tendency  ot  this  epithelium  to 
take  on  epithelial  changes,  and  the  connective  tissue  ready  to 
hypertrophy,  with  an  acute  inflammation  or  irritation  from  any 
of  the  causes  mentioned  above,  is  it  not  most  natural  for  this 
state  to  be  converted  into  a  chronic  condition  from  the  effects  of 
half  heated  air,  proximity  of  a  congested  pharynx,  a  constant 
dripping  of  disorganized  mucus  from  the  vault  of  the  pharynx 
and  the  hyperasmia  consequent  upon  the  constant  effort  to  clean 
the  larynx? 

Yet,  I  cannot  fully  agree  that  the  most  of  these  cases  where 
enlargements  occur  are  the  pachydermia  of  Virchow  or  the  quasi- 
tumors  of  Tissiers.  It  is  indeed  an  enlargement,  and  hyper- 
trophy will  occur  elsewhere  if  the  mucous  membrane  is  irritated 
and  hyperaemic.  That  hypertrophic  and  hyperlastic  conditions 
are  conductive  to  the  more  prompt  establishment  of  benign  and 
malignant  tumors.  I  agree,  in  as  much  as  the  larynx  is  prone  to 
take  on  such  changes. 

Armstrong,  writing  in  the  New  York  Medical  Journal,  Janu 
ary  1898,  on  the  aetiology  of  chronic  broncho- nasal  and  gastro- 
intestinal catarrh,  refers  to  the  results  of  deflected  septum,  ex- 
ostoses, enchondromata  and  true  hypertrophy,  and  says  this 
condition,  "is  almost  the  universal  of  hypertrophic  pharyngitis 
and  laryngitis,"  and  also,  "mouth  breathing  or  what  is  practica 
the  same,  breathing  solely  th'-ough  the  inferior  meatus, because 
of  obstruction  in  the  upper  part  of  the  nose  is  the  exciting  agent 
pro'uc  nglary.  gitis,  which  eventually  resolves  itselfinto  chronic 
hypertrophic  laryngiti  .  By  this  obstiuction  the  air  is  shutout 
of  its  proper  physiological  channels  and  is  not  properly  warmed 
moistened  and  as  a  result  the  moisture  of  the  lower  pharynx 
and  larynx  is  soon  consumed  and  a  dry  burning  irritation  of  the 
larynx  is  set  up,  described  by  patients  as  a  choking  sensation, 
a  feeling  as  if  a  lump  was  in  the  throat  and  often  erroneously 
diagnosed  by  physicians  as  globus  hystericus.  Chronic  hyper- 
trophic laryngitis  sooner  or  later  causes  a  chronic  irritation  fol- 


WOODWARD-CHRONIC  LARYNGITIS    ETC.  j.^ 

Jowed  by  a  persistent  hacking  coug^h.  The  lungs  subjected  to 
this  constant  concussion  soon  take  on  a  bronchial  inflammation 
which  furnishes  a  nidus  for  the  fibercular  bacillus." 

From  this  you  see  it  is  well  to  keep  constantly  before  us  the 
three  points  laid  down  by  Greville  Macdonald:— 

I.  Air  respired  through  the  nostrils  is  brought  nearly  to  the 
temperature  of  the  blood. 

2     Dry  air  becomes  saturafd  with  moisture. 

3.  Exchange  of  gases  in  the  air  and  in  the  blood  of  the  mu- 
cous membrane  takes  place. 

The  air  current,  as  suggested  by  Kayser  and  Paulsen,  hugs 
the  septum  and  passes  up  over  the  inferior  turbinate  making  a 
semi-circle  before  passing  into  the  larynx.  This  is  important 
to  remember,  but  not  essential.  As  all  of  the  water  m  a  river 
does  not  run  in  the  channel,  so  with  the  air  current.  It  is  the 
total  mucous  surface  that  is  presented  by  the  nose  and  accessory 
cavities  that  supplies  the  proper  amount  of  heat.  The  hyper- 
trophies and  obstructions  that  damage  and  render  the  air  irri- 
tant to  the  mucous  membrane  of  probably  an  already  inflamed 
larynx.  Therefore  you  can  see  how  fast  riding  on  the  bicycle 
is  detrimental  to  those  suffering  with  any  form  of  laryngitis. 
I  have  treated  several  cases  of  bicycle  laryngitis  lately.  This 
should  be  remember  d, especially  by  those  who  ride  daily 
through  crowded  streets— keep  the  mouth  shut  and  breathe 
through  the  nostrils  as  nature  intended. 

In  considering  the  results  of  chronic  laryngitis,  outside  of  the 
risk  to  the  lungs,  there  are  many  points  of  vital  importance  to 
our  personal  comforts  as  well  as  of  special  interest  to  the  future 
welfare  of  the  human  race.  The  comforts  of  home  life, the  social 
problem,  the  drawing  room  and  the  concert,  the  theatre  and  the 
counting  room,  the  pulpit  and  the  bar  will  all  have  to  decide 
this  question  some  way.  They  will  feel  its  influence,  now  and 
also  according  to  the  theory  of  heredity,  and  will  naturally  ex- 
pect the  advance  of  medicine  to  correct  its  evil  tendencies.  It 
will  be  a  glorious  day  when  cuspidors  become  relics  and  "hawk- 
ing and  hemming"  are  heard  no  more. 

The  eloquence  of  the  pulpit  and  the  bar,  the  passionate  and 
living  harmonies  of  our  sweetest  vocalists  are  at  the  mercy  of 
the  larynx.      Nothing  ean  lull  to  peaceful  oblivion  dull  care  more 


WOODWAED.-CHRONIC  LARYNGITIS,    ETC. 
144 

promptly  than  a  well  turned  voice.  Yet  daily  cracked  registers, 
false  pitch  and  narrow  compass  are  forced  into  baritones,  con- 
traltos and  tenors  with  an  inharmonious  mixture  of  head  and 
chest  tones  at  the  expense  of  the  vocal  cords.  Hypertrophic 
enlargement  and  epithelial  changes  produce  false  relationship 
and  imperfect  co-ordination  of  the  normal  muscular  action  of 
the  larynx,  and  a  resultant  hoarseness  and  fatigue  of  voice,  and 
in  many  cases  a  paresis  of  one  of  the  vocal  cords,  as  seen  in 
several  of  the  cases  above,  or  so  much  muscular  lassitude  that 
phonation  becomes  almost  impossible. 

In  several  of  the  cases  reported  there  was  unilateral  paresis 
with  false  position  of  the  affected  cord  upon  attempt  at  phona- 
tion;  in  none  of  them,  however,  was  there  complete  paralysis  or 
the  cadaveric  position,  but  in  all  a  loss  of  voice  simply  from 
the  lack  of  power  of  approximation. — a  lack  of  power  in  the 
arytenoid  cartilages  to  sustain  themselves  in  a  fixed  position  so 
to  give  the  cricothyroids  a  chance  to  stretch  the  bands  so  that 
the  register  could  be  sounded. 

The  arytenoid,  the  cnco-thyroids  and  the  thyroarytenoids  are 
the  muscles  that  receive  the  brunt  of  the  influence. 

Sajous  found  hoarseness  in  professional  singers  when  there 
was  lack  of  lubrication  of  the  cords.  These  cases  were  of  course, 
found  in  the  dry  catarrh  of  the  larynx.  Botey  cured  a  case  of 
supposed  laryngeal  obstruction  by  treating  the  mucous  mem- 
brane of  the  nose.  Raulin  of  Marseilles,  restored  the  voice  of 
a  singer  by  treating  double  hypertrophies  of  the  posterior  sep- 
tum. There  was  a  lose  of  tone  in  the  upper  register  and  he 
called  it  muscular  fatigue.  Uspensky  also  restored  the  voices 
of  two  singers  by  treating  the  hypertrophies  of  the  middle  tur- 
binates.    There  was  impaired  resonance  and  false  register. 

Trifiletti  lays  stress  upon  morbid  conditions  of  the  nose  and 
naso-pharnyx  as  factors  in  causing  aphonia.  Steward,  of  Lon- 
don  reported  twocures  of  unilateral  paresis, right  side, both  right 
middle  turbinates  enlarged  pressing  upon  the  septum. 

Rault  of  Paris  refers  to  eight  cases  of  paretic  aphonia  cured 
by  nasal  treatment.  Hunter  Mackenzie  speaks  of  tuberculou  s 
laryngitis  and  tumor  formation  as  sequelae  of  chronic  laryngitis. 

There  have  been  many  cases  reported  in  the  last  half  decade, 
and  its  evil  influence   recognized  for  many  years,    though   few 


POPE.-NEUKASTHENIA.  -.-_ 

papers  discuss  the  damage  done  to  the  voice  as  it  deserves  and 
its  significance  in  diagnosing  foreign  bodies  in  the  larynx. 

Voice  production  is  not  simply  the  result  of  a  harmonious 
control  of  health  and  chest  tones  and  the  ability  to  force  the 
cords  into  a  tonal  relation,  but  is  the  correctness  of  pitch  and 
range  of  compass  happily  poised  by  perfect  control  of  the  higher 
and  lower  registers  through  a  specially  cultivated  will  power  to 
fix  the  cords  and  use  the  auxiliary  muscles.  To  accomplish  this 
a  free  air  supply  is  essential, not  through  the  mouth,  but  through 
the  naso-pharynx  with  unencumbered  vocal  cords,  flexible  and 
active,  with  free  use  of  the  auxiliary  muscles  and  perfect  pecto- 
ral breathing.  These  are  hardly  obtainable  with  a  stenosed 
nasal  cavity  and  chronically  inflamed  and  enlarged  larynx. 

Healthful  environments  and  corrected  nasal  troubles  will  do 
a  great  deal  towards  obviating  these  calamities.  A  healthy  nose 
will  seldom  need  blowing  and  a  sound  throat  will  not  often  need 
clearing. 


Clinical  Xecturee, 


NEURASTHENIA. 


Bv  CuRRAN  Pope,  M.  D.  Prof,  of  Diseases  of  the  Mind  and  Ner- 
vous System,  and  Electro-therapeutics  in  the  Louisville 
Medical  College, consulting  Neurologist  to  the  Lcuisville 
Medical  College  Hospital,  consulting  Neurologist  to  the 
Louisville  City  Hospital,  Prof,  of  Hygiene  in  the  Kentucky 
Military  Institute:  Member  of  the  American  Medical,  Am- 
erican Electro-Therapeutic, Central  and  North  Eastern  Ken- 
tucky Medical  Associations;  Fellow  of  the  Louisville  Acade- 
my of  Medicine,  and  Superinteddent  of  the  Curran  Pope 
Sanatorium. 


W 


K.  Age  42,  ■  born  in  America,  occupation  farmer  and 
married.  Four  healthy  children  He  began  last  spriuj^ 
with  a  swelling  of  the  feet  and  lower  limbs   accom  >;- 


^  .g  POPE.— NEURASTHENIA. 

nied  by  numbness  and  headache  of  a  dall  and  heavy  character 
with  attacks  of  dizziness  and  shortness  of  breath. 

His  family  history  is  as  foUjws;  his  father  died  at  the  age  of 
72  of  pneumonia,  and  his  mother  at  60  with  measles.  He  has 
one  whole  brother  and  two  half  brothers  that  are  healthy;  four 
sisters,  all  healthy,  none  of  them  nervous.  In  none  of  his  family 
is  there  consumption,  cancer  or  mental  trouble. 

In  his  early  life  he  had  usual  diseases  of  childhood.  He  has 
suffered  from  none  of  the  more  serious  neuroses  of  childhood, 
never  having  had  any  epiletoid  convulsions  or  chorea;  but  has 
been  subject  to  night  terrors  and  sleep  walking,  technically 
known  as  favor  nocturnus  and  somnambulism. 

Formerly  he  used  liquor  to  excess,  indulging  pretty  steadily 
with  an  occasional  heavy  spree.  He  has  also  used  tobacco  to 
excess,  chewing,  not  smoking.  He  has  never  had  any  veneral 
diseases  or  contamination  and  states  that  he  has  had  a  good  con- 
stitution. 

He  complains  of  discomfott  and  distention  in  the  gastro-in- 
testinal  tract  and  that  his  limbs  are  uncomfortable,  with  an 
"achy  feeling  in  the  bones"  as  he  calls  it.  He  says  he  suffers 
from  palpitation  of  the  heart  upon  active  movement  and  that  at 
times  he  has  attacks  a  good  deal  like  fainting.  He  complains 
of  a  headache,  neither  increased  by  exertion  nor  lessened  by 
rest,  that  is,  constant,  dull  and  heavy.  He  says  he  sleeps  fairly 
well,  that  he  dreams  little,  awakening  in  the  morning  feeling 
worse  than  when  he  went  to  bed  and  that  he  usually  feels  better 
along  toward  the  latter  part  of  the  day. 

As  you  see  he  is  a  rather  thin  man,  he  has  very  little  adipose 
tissue,  but  he  tells  us  that  he  has  lost  very  little  flesh  and  that 
this  has  been  his  general  condition  of  build  through  the  whole 
of  his  life.  There  is  considerable  irregularity  in  the  cranium 
and  you  will  notice  that  there  is  quite  a  difference  in  the  level 
of  the  eye-brows.  The  general  formation  of  the  face  is  prog- 
nathic, and  the  nasal  bones  show  considerable  irregularity.  The 
palate  is  high  although  it  is  hardly  sufficiently  high  to  mark  it 
as  degenerate. 

He  suffers  from  nervousness  and  mental  depression  nearly  all 
the  time  and  is  very  much  worse  in  warmer  than  in  cooler  weather 
He  believes  he  has  made  some  improvement  in  his  mental  con- 
dition since  the  weather  has  changed.       As  is   very  con"imon  in 


P0PE.-NEURASTI1ENIA.  _ 

these  cases  he  is  excessively  irritable,  but  at  the  same  time 
he  feels  stupid  and  heavy  and  tired  and  just  wants  to  be  let 
alone.      He  has  no  "Get  up  and  get"  as  he  expresses  it. 

His  general  strength  he  says  especially  in  his  arms,  is  very 
good;  that  he  can  go  a  little  distance  all  right;  then  he  begins 
to  give  out  in  his  legs  and  in  a  short  he  is  compelled  to  give  up. 
He  suffers  from  a  fine  vibratory  tremor  on  the  extension  of  the 
arm  and  fingers.  On  testing  him  wc  find  that  he  exhibits  no 
ataxia.  The  reflexes  are  active  and  very  much  so  upon 
reinforcement. 

His  tongue  is  coated  heavily  and  stained  with  tobacco.  His 
bowels  are  constipated  alternating  with  diarrhoea,  which  is  prob- 
ably the  result  of  fermentation  and  intestinal  indigestion.  He 
says  immediately  after  eating  and  more  or  less  all  the  time  he  is 
distended  and  his  abdomen  feels  heavy  just  like  he  had  a  weight 
in  it.  He  often  has  a  queer  feeling  in  his  abdomen  and  some 
pain.     His  eye  sight  is  normal  and  his  hearing  good. 

This  case  is  evidently  one  of  neurasthenia.  In  all  probability 
in  this  case  we  have  a  considerable  toxemia.  Neurasthenia  to 
a  certain  extent  is  an  American  disease,  not  so  much  American 
novk  as  it  was  ten  years  ago:  nevertheless  the  purest  and  most 
distinctive  types  of  this  disease  are  found  in  this  country.  It  is 
possibly  due  partly  to  the  varying  factors  that  go  to  make  up 
the  Nation.  The  prominent  features,  however,  are  the  peculiar 
political, religious,  scientific  and  business  activity  of  the  country. 
Nowhere  on  the  face  of  the  earth  are  there  such  premiums  offer- 
red  for  advancement  as  to  him  who  acquires  much  in  his  parti- 
cular line  of  work  or  particular  line  of  money  getting.  As  a 
result  of  this  men,  and  women  too  for  that  matter,  are  apt  to 
overtax  the  capacity  of  the  nervous  system  for  normal  and  proper 
work.  Many  persons  are  unquestionably  handicapped  from  the 
start  by  .i  poor  resistance,  imperfect  heredity  and  unstaple  con- 
stitution,and  apt  to  develop  the  varying  phrases  of  neurasthenia 
upon  the  slightest  strains.  The  tension  and  tone  of  the  nervous 
system  is  much  lowered. 

As  a  rule  in  such  cases  as  we  have  before  us  the  prognosis  is 
good.  This  man  in  all  likelihood  will  recover  from  his  trouble. 
The  average  duration  of  the  treatment  of  a  case  of  neurasthenia 
is  not  to  be  measured  in  days  but  in  weeks  and  months. 

In  regard  to  the  treatment  of  this  case,  I  can  do  nothing  more 


J  .g  SOCIETY  REPORTS. 

to-day  than  to  go  over  briefly  the  particuliar  treatment  that  we 
would  give  this  case  from  a  clinical  and  private  practice  stand- 
point. 

We  will  put  this  man  on  laxatives  for  a  while.  There  is 
nothing  more  advantageous  than  combining  with  the  laxative 
treatment  antisepsis  and  super-alimaentation  especially  in  the 
intestinal  tract.  To  accomplish  this  we  can  use  the  following 
prescription. 

IJ — Aloin gr.    1-20 

Phenacetin gr.    ss-j 

Salol gr.  V. 

Taka-diastase gr.   ss-ij 

Camph.  Monobro  ....  gr.  v. 
You  can  use  either  aloin  or  cascara  sagrada.  I  prefer  to  use 
aloin  in  young  people  and  cascara  sagrada  in  older  persons  or 
persons  who  have  had  neurasthenia  for  a  longtime.  If  you  find 
the  aloin  or  cascara  unpleasant  we  can  add  a  little  belladonna 
to  the  prescription  but  I  rarely  do  so.  I  prefer  to  use  phenace- 
tin. It  certainly  lessens  nerve  irritation  and  depression  and  at 
the  same  time  acts  to  a  certain  extent  as  an  antiseptic.  We 
will  use  in  conjunction  herewith  the  usual  hydrotherapeutic  and 
electrical  treatment  I  have  heretofore  suggested. 


Society?  I^cpors, 


NEW  YORK  ACADEMY  OF  MEDICINE. 

Section  in  Orthopaedic  Surgery, 
Meeting  of  December  17th,  1897. 


Dr.  A.  M.  Fhclphs  read  a  paper  entitled:  "A  Consideration 
of  Some  of  the  Pathological  and  Mechanical  Problems  of  Hip 
Disease."  He  presented jhe  view  that  Nature  attempted  to  re- 
pair the  lesion  producing  hip  disease  by  inflammatory  action 
which  was  a  normal  process  of  repair  until  the  inoculation  of 
germ  life  which  marked  the  beginning  of  disease  in  the  area  of 
inflammation      The  absence  of  inoculation  gave  rise  to  cphcm- 


SOCIETY  REPORTS .  j  ^  n 

eral  cases  of  hip  disease  which  rapidly  recovered  without  defor- 
mity or  disability,  but  inoculation  gave  rise  to  the  ordinary  type 
of  the  disease.  If  the  phagocytes  were  weakened  by  the  stru- 
mous condition  of  the  patient,  they  failed  to  destroy  the  germs. 

If,  however,  germ  life  was  destroyed,  repair  went  on  and  the 
parts  were  restored  to  their  normal  condition.  Cavities  and 
foci  produced  in  the  course  of  hip  disease  by  the  slow  growth  of 
the  bacilli  of  tuberculosis  might  be  inoculated  by  the  rapidly 
growing  pyogenic  cocci  when  a  hot  and  possibly  painful  abscess 
appeared  and  called  for  the  knife  and  drainage.  The  adduction, 
flexion  and  inward  rotation  attending  the  third  stage  found  a 
mechanical  explanation  in  the  fact  that  when  the  limb  passed 
twenty-five  degrees  of  flexion  the  adductors  became  internal 
rotators,  the  external  rotators  became  adductors  and  the  tensor 
vaginae  femoris  became  a  powerful  inward  rotator.  In  the  ap- 
plication of  mechanical  treatment  it  should  be  remembered  that 
the  powerful  groups  of  muscles  acting  upon  the  thigh  did  not 
act  on  an  axis  with  the  shaft  but  nearly  on  a  line  parallel  with 
the  axis  of  the  neck  of  the  femur.  Lateral  traction,  therefore, 
should  be  made  in  the  line  of  the  axis  of  the  femural  neck  and 
not  of  the  shaft. 

Dr.  G.  R.  Elliott  said  that  in  hip  disease  we  had  a  depraved 
process.  The  whole  system  was  at  a  low  ebb  that  tended  to 
favor  the  development  of  the  disease.  He  thought  that  this  con- 
dition of  inactivity  required  the  use  of  some  form  of  apparatus 
which  did  not,  as  all  the  instruments  now  in  use  did,  subject 
every  part  of  the  child's  body  to  great  expense  for  the  sake  of 
the  hip.  The  ideal  splint  of  the  future  would  not  lock  up  so 
much  of  the  body  by  apparatus  but  would  fix  only  the  diseased 
joiat. 

Dr.  R.  H.  Sayre  advocated  the  use  of  traction  to  fix  the  joint, 
give  it  physiological  rest  and  relieve  the  pressure  to  which  the 
diseased  bone  was  subjected.  He  thought  that  it  was  difficult 
to  apply  lateral  traction  by  a  splint,  but  in  bed  lateral  traction 
was  easily  applied  and  added  to  the  patient's  comfort.  In  child- 
ren, however,  in  whom  the  neck  was  nearer  in  line  with  the  shaft 
of  the  femur  than  in  the  adult,  he  believed  that  longitudinal 
traction  was  sufficient.  He  thought  it  well  to  apply  massage  to 
overcome  the  muscular  atrophy  of   disease,    but  it  took  a  great 


jCQ  SOCIETY  REPORTS. 

deal  of  care  to  limit  the  application  to  the  sound  part  and  not 
interfere  with  the  inflamed   joint. 

Dr.  R.  H.  Hanky  held  that  all  pus  accumulations  about  a 
joint  should  be  evacuated  early  and  thoroughly.  He  asked  Dr. 
Phelp's  opinion  of  the  intra-articular  injections  of  solutions  of 
iodoform. 

Dr.  Fhdphs  said  that  filling  a  joint  with  an  insoluable  com- 
pound did  more  harm  than  good.  If  he  found  a  joint  in  which 
there  was  fluid,  he  evacuated  it. 

Dr.  A.  B.  Judson  said  that  the  destruction  of  the  head  and  ace- 
tabulum was  often  cited  as  an  evidence  of  the  bad  effects  of  mus- 
cular contraction  and  of  the  necessity  of  making  traction.  He 
thought  that  this  destruction  was  rather  an  evidence  of  the  bad 
effects  of  the  pressure  made  by  the  weight  of  the  body,  as  pa- 
tients with  hip  disease,  if  unmolested,  were  in  all  except  the 
most  advanced  stages  on  their  feet  as  much  as  well  children. 
He  believed  that  traction  was  the  best  method  of  promoting 
fixation  and  in  painful  stages  it  was  indispensable,  but  that  re- 
moving the  weight  of  the  body  from  the  joint  was  also  an  indis- 
pensable part  of  the  treatment  and  useful  through  far  longer 
periods  than   traction. 

Dr.  T.  H.  Myers  had  made  a  careful  study  of  the  ephemeral 
cases  and  believed  that  the  lesion,  of  whatever  nature  it  might 
be,  was  in  the  bone  itself.  He  would  make  a  distinction  between 
these  cases  and  rheumatic,  gonorrhoea!  or  other  affections  of  the 
joint  cavicy  and  ligaments.  He  could  not  recall  any  acute  case 
of  hip  disease  which  had  not  been  relieved  by  longitudinal  trac- 
tion alone. 

Dr.  R.  Whitman  said  that  the  breaking  down  of  bone  appeared 
to  be  the  eft'ect  of  a  destructive  process,  aggravated  by  the  fric- 
tion of  the  diseased  surfaces  upon  one  another,  by  the  weight 
and  strain  of  use  in  the  attitudes  of  deformity  and  by  the  mus- 
cular spasm  which  forced  the  diseased  parts  together.  The  in- 
tensity of  the  spasm  was  in  inverse  proportion  to  the  fixation 
and  rest  that  could  be  assured.  When  the  patient  was  recumbent 
the  most  important  means  of  fixing  the  joint  was  traction.  The 
ambulatory  brace  should  remove  the  weight  of  the  body  from 
the  weakened  part,  but  it  was  so  ineffective  in  fixation  that  its 
use  should  be  combined  with  splinting  of  the  joint.  He  had 
always  insisted  that  the  hip  should  be  slightly  abducted. 


SOCIETY  REPORTS.  j  _  j 

Dr.  Phelphs  said  that  abdnction  should  be  avoided.  It  was 
■one  of  the  difficult  conditions  to  correct  in  the  first  and  second 
stages. 

Dr.  Judsons^xdi  \.hz.X.  in  recovery  with  anchylosis  abduction 
was  desirable.  It  gave  a  factitious  length  to  a  limb  which  was 
probably  really  shortened  and  saved  the  use  of  a  high  sole  or 
reduced  its  height. 

Dr.  Sayre  thought  that  the  limb  spould  be  in  as  nearly  normal 
a  position  as  possible,  neither  abducted  nor  adducted. 

Dr.  H.  L.  Tlzj'^r  thought  that  about  five  degrees  of  abduc- 
tion would  compensate  for  some  of  the  shortening  and  make  the 
limb  more  useful. 

Dr.  Phelphs  said  that  anchylosis  was  due  to  the  severity  of 
the  inflamaiation,  the  character  of  the  disease,  the  destruction 
of  bone  and  contraction  of  cicatricial  tissue  :;bout  the  joint.  It 
was  prevented  by  the  use  of  an  apparatus  which  seized  the  pelvis 
and  fixed  the  joint  from  the  commencement  of  the  treatment 
until  the  patient  was  cured.  The  joint  being  thus  held  at  per- 
fect rest.  Nature  went  on  in  her  effort  to  cure,  uninterrupted  by 
the  trauma  of  motion.  The  splint  was  not  used  to  overcome 
deformity,  but  merely  to  hold  the  limb  in  a  perfectly  straight 
position  after  the  deformity  was  corrected  by  bed   treatment. 

DEFORMITIES    FOLLOWING    TYPHOID    FEVER. 

Dr.  W.  R.  Townsend  presented  a  boy  19  years  of  age  who  had 
complained  of  spinal  pain  and  stiffness  since  recovery  from 
typhoid  fever  last  February.  The  vertebral  column  was  very 
rigid  with  a  slight  curve  towards  the  right  in  the  lower  dorsal 
region  and  a  posterior  curve  of  the  lower  dorsal  and  the  entire 
lumbar  region.  There  were  also  a  number  of  swellings  dis- 
tinctly connected  with  the  bone  in  different  parts  of  the  body 
resembling  the  cold  abscesses  of  tubercular  subjects  and  syphi- 
litic nodes.  They  were  not  very  soft  and  there  was  no  fluctua- 
tion. The  general  health  had  been  poor  since  the  fever.  Par- 
sons, of  Johns  Hopkins  University,  had  described  such  swell- 
ings as  appearing  several  months  after  typhoid  fever.  He  had 
found  in  them  the  typhoid  bacillus,  the  staphylococcus  and  the 
bacillus  coli  communis  and  had  advocated  total  extirpation  of 
these  foci. 

Dr.  Sayre  thought  the  boy  might  be  suffering  from  hereditary 


J--  SOCIETY   REPORTS. 

syphilis  which  had  first  made  its  appearance  when  his  health 
was  broken  down  by  the  attack  of  typhoid  fever.  If  local 
treatment  was  necessary  the  foci  might  be  incised  and  scraped 
and  packed  from  the  bottom.  As  the  epiphysis  is  involved  in 
several  instances  enucleation  would  endanger  the  usefulness  of 
the  joints.  He  called  attention  to  the  girdle-mark  which  is  a 
pathognomonic  sign  of  disease  of  the  spine  and  advised  treat- 
ment as  of  an  ordinary  case  of  tuberculous  disease  of  the  spine. 

Dr.  V.  P.  Gibney  advised  that  a  trial  of  anti-syphilitic  treat- 
ment be  followed  be  general  constitutional  treatment,  the  ad- 
ministration of  cod-liver  oil,  etc.  He  could  see  no  advantage 
likely  to  follow  cutting  out  the  foci.  Spinal  rigidity  after 
typhoid  fever  was  due  to  a  mild  periostitis  about  the  points  of 
exit  of  the  nerves.  He  thought  that  forcible  correction  with 
anaesthesia  would  be  excellent  treatment  in  this  case.  He  had 
seen  a  number  of  tyohoid  hips.  One  ol  them  was  under  treat- 
ment by  repeated  forcible  motion  under  anaesthesia  followed  by 
massage. 

Dr.  Whitman  thought  that  the  spinal  deformity  was  the  most 
important  feature  of  the  case  and  that  it  required  immediate 
correction.  He  thought  that  the  girdle-wrinkle  was  not  caused 
by  muscular  spasm  but  was  simply  a  fold  in  the  abdominal  wall 
answering  to  the  projection  backwards  which  had  taken  the 
place  of  the  normal  lumbar  lordosis. 

Dr.  Sayre  said  that  he  had  noticed  the  girdle-wrinkle  in  many 
cases.  It  would  be  higher  or  lower  according  to  the  location  of 
the  disease.  It  was  due  to  muscular  spasm  which  accompanied 
any  muscle  subject  to  irritation  and  joint  inflammation.  It  was 
diagnostic  of  Potts'  disease  and  was  present  even  when  there 
was  no  appreciable  projection. 

Dr.  Townsend  sa.\d.  he  had  not  thought  seriously  of  taking  the 
foci  out  as  to  do  so  would,  in  nearly  every  instance  in  the  patient 
in  question,  involve  opening  into  a  neighboring  joint.  He 
would  put  the  boy  upon  anti-syphilitic  treatment  and  later  would 
probably  consider  the  other  suggestions  made. 

ABSCESSES    WITH    PERFORATION    OF    THE    BLADDER. 

Dr.  Myers  related  the  case  of  a  boy  lo  years  old  who  had  left 
hip  disease  with  many  sinuses  and  waxy  liver.  A  discharge  of 
urine  from  a  sinus  in  the  inguinal  region  continued  for  two  weeks 


SOCIETY  REPORTS .  I  5  3 

No  pus  was  noticed  in  the  urine.  For  a  time  there  was  pain  in 
the  lower  part  of  the  abdomen.  The  urine  contained  hyi  line 
and  granular  casti,  a  few  pus  cells  attached  to  casts,  no  sugar 
and  a  small  amount  of  albumen.  Specific  gravity  loio.  The 
child  was  kept  lying  on  the  opposite  side.  Dr.  Myers  also  re- 
lated the  case  of  a  girl  15  years  old  who  had  many  abscesses 
from  disease  of  the  left  hip.  An  abscess  appeared  above  Pou- 
part's  ligament  on  the  right  side  with  abdominal  pain.  The 
muscles  of  the  abdominal  wail  were  rigid.  Large  quantities  of 
pus  were  painfully  passed  with  the  urine.  The  abscess,  after 
extending  towards  the  left,  ruptured  and  with  the  escape  of  a 
a  quart  of  purulent  fluid  the  pus  disappeared  from  the  urine. 
Both  of  the  patients  recovered  from  the  perforation.  In  the 
first  patient  the  flow  was  from  the  bladder  outward,  in  the 
second  from  the  abscess  into  the  bladder.  He  also  recalled  two 
cases  in  which  there  was  intestinal  perforation  with  discharge 
of  intestinal  contents  through  the  sinus.  Both  patients  speedily 
died. 

Dr.  Townsend  recalled  a  case  of  psoas  abscess  in  which  pus 
passed  for  three  years  through  a  perforation  in  the  rectum. 

Dr.  Sayre  recalled  a  case  of  hip  disease  in  an  adult  in  which 
an  abscess  discharged  through  the  bladder.  The  patient  sur- 
vived the  complication  ten  years  and  is  still  alive.  In  another 
patient  in  whom  both  hips  were  diseased  on  one  side  there  was 
perforation  into  the  intestine  with  escape  of  gas  from  an  ex- 
ternal sinus.  This  hip  recovered  with  motion  while  the  other 
hip,  in  which  there  was  no  abscess,  recovered   with  anchylosis. 


RICHMOND   ACADEMY  OF  MEDICINE. 
The  Progress  of  Serum  Therapy. 


The  first  mention  of  the  employment  of  the  idea  of  serum- 
therapy  is  that  in  the  recorded  practice  of  inoculating  patients 
as  a  prophylactic  measure  against  smallpox,  employed  at  the 
beginning  of  the  eighteenth  century  in  Turkey.  Inoculation 
gave  way  before  the  more  desirable  method  of  vaccination.   The 


I-.  SOCIETY  REPORTS. 

number  of  lives  which  Jenner's  discovery  has  saved  is  well  nigh 
incalculable.  The  first  mentien  of  the  use  of  serum  is  to  be 
found  among  the  Germans,  who  employed  the  treatment  under 
the  name  of  Isopathy,  about  the  middle  of  the  century.  To 
what  extent  it  was  used,  and  with  what  success  it  was  credited 
by  them,  is  not  definitely  stated,  but  it  must  have  impressed 
them  favorably,  for  a  variety  of  isopathic  preparations  made 
their  appearance  under  such  names  as  "phthisia,  hydrophobia, 
scarlatina,"  etc. 

Diphtheria. — The  history  of  the  development  of  the  antitoxin 
treatment  of  diphtheria  is  so  well  known,  and  its  acceptance 
now  so  universal,  that  it  would  be  useless,  even  if  the  limits  of 
this  report  rendered  it  possible  to  go  fully  into  details  on  these 
points.  Even  at  the  time  that  your  com.mittee  was  appointed 
it  could  be  said  that  a  sufficiently  extensive  trial  of  the  antitoxin 
treatment  of  diphtheria  had  been  made  to  remove  the  fears 
which  many  had  entertained  as  to  its  action,  and  to  place  the 
remedy  in  an  assured  position  as  one  of  inestimable  worth. 

During  the  past  year  statistics  from  many  and  varied  sources 
have  appeared,  all  tending  still  further  to  increase  the  confidence 
of  the  profession  in  the  remedy,  and  to  demonstrate  the  saving 
of  life  which  it  has  accomplished.  Many  who  were  sceptical 
have  been  convinced  by  the  unanswerable  argument  of  statis- 
tics whose  authenticity  could  not  be  questioned,  until  to-day  it 
may  be  said  that  but  few  physicians,  indeed,  who  have  given 
the  subject  careful  consideration  do  not  accord  to  the  remedy 
even  more  value  than  was  at  first  claimed  for  it  by  its  staunchest 
advocates. 

Only  two  sets  of  these  statistics  will  be  referred  to,  not  be- 
cause they  are  more  favorable  than  others,  but  on  account  of 
the  large  number  of  cases  recorded  in  them,  and  because  they 
represent  such  diversity  in  the  class  of  casses  treated. 

The  report  of  the  committee  of  the  American  Pediatric  So- 
ciety, presented  at  its  last  meeting,  includes  1,704  cases  of 
laryngeal  diphtheria  which  occurred  in  the  practice  of  422  phy- 
sicians in  the  United  States  and  Canada.  In  this  report  the 
following  points  are  among  the  most  prominent:  Before  the 
use  of  antitoxin  it  was  estimated  that  90  per  cent,  of  laryngeal 
diphtheria  cases  required  operation,  whereas  now,  with  the  use 
of  antitoxin,  only  39.21  per  cent.,  require  it.      The  mortality  in 


society  reports. 

^  j5 

the  whole  series  of  1,704  cases  was  21.12  per  cent.  (360  deaths) 
In  the  non-operated  cases  the  mortality  was  17.18  per  cent.  (178 

deaths.     The  mortality  in  the  operated  cases  (27.24  per  cent. 

182  deaths)  shows  even  more  remarkable  results.  Before  the 
use  of  antitoxin  only  27  per  cent,  reccvered;  now  only  27.24  per 
cent.  die. 

The  other  report  to  which  reference  will  be  made  is  the 
"Second  Report  of  Medical  Superintendents  upon  the  Use  of 
Antitoxic  Serum  in  the  Treatment  of  Diphtheria  in  the  Hos- 
pitals of  the  Metropolitan  Asylum's  Board  during  the  year  i8g6." 
(London).  In  these  hospitals  during  1896  antitoxin  was  used 
in  71.3  per  cent,  of  all  cases  of  diphtheria,  the  remedy  not  being 
employed  in  moribund,  mild, a  doubtful  cases.  The  total  death 
rate  during  1896  (under  antitoxin)  was  20.8  per  cent.  ;  that  of 
1894  (without  antitoxin),  although  then  considered  remarkably 
low,  was  29.6  per  cent.  This  represented  a  saving  of  365  lives. 
It  is  well  known,  however,  that  only  during  the  early  days  of 
the  disease  does  antitoxin  exert  its  full  beneficial  effect;  and 
hence,  while  the  above  figures  show  a  difference  in  the  total 
death  rate  of  only  8.8  per  cent.,  the  difference  in  cases  treated 
on  the  first  day  was  17.8  per  cent.;  on  the  second  day,  14.2  per 
cent.  ;  on  the  third  day,  11. 7  per  ent.  ;  on  the  fourth  day,  9.1 
per  cent.  ;  and  on  the  fifth  day  or  later,  6.  2  per  cent.  Laryngeal 
cases  were  attended  with  a  mortality  of  62  per  cent,  in  1894; 
29.6  per  cent,  in  1896.  Operated  laryngeal  cases  had  a  death 
rate  of  70.4  per  cent,  in  1894:  41  per  cent.  1896.  It  is  the  opin- 
ion of  the  superintendents  that  there  has  been  no  reduction  in 
the  frequency  of  complications  of  the  disease  as  a  result  of  an- 
titoxin treatment,  except  ii  the  case  of  nephritis,  which  occurs 
less  often.  In  fact,  it  would  seem  as  if  the  other  complications 
occur  even  more  frequently  than  formerly.  This,  however  is 
only  apparent,  and  is  due  to  the  closer  observations  which  are 
now  made,  and,  even  more,  to  the  fact  that  many  severe  cases, 
which  would  have  died  under  other  treatment,  now  recover,  and 
these  are  naturally  more  prone  to  develop  complications. 

In  this  report  the  general  results  of  antitoxin  treatment  are 
summed  up  as  follows:  i.  Diminution  of  faucial  swelling;  2. 
Lessening  of  irritating  and  offensive  discharge  from  the  nose; 
3.  Limitation  of  extension  of  membrane;  4.  Earlier  separation 
of  exudate;  5.  Limitation  and  earlier  separation   of  membrane 


J -5  SOCIETY  EEPORTS.. 

in  laryngeal  cases;  6.  Improvement  in  general  condition  and- 
aspect  of  patients;  7.  Prolongation  of  life,  in  fatal  cases,  to  an 
extent  not  obtained  with  former  methods  of  treatment. 

It  has  been  claimed  by  those  who  refuse  to  recognize  the  value 
of  diphtheria  antitoxin,  that  the  favorable  results  shown  in  the 
statistics  of  the  past  few  years  arc  due  to  other  factors  than  the 
employment  of  antitoxin.  By  some  it  is  held  that  the  type  of 
the  disease  has  become  milder;  others  that  since  the  widespread 
application  of  bacteriologic  diagnosis,  cases  are  now  called  diph- 
theria which  were  formerly  not  so  classified;  or,  again,  that 
moribund  cases  and  cases  treated  after  the  fifth  day  of  the  dis- 
ease are  excluded  in  many  of  the  statistics.  The  first  report  to 
which  reference  has  been  made  above,  answers  fully  the  first 
objection,  since  it  deals  with  only  laryngeal  cases,and  laryngeal 
diphtheria  can  never  be  considered  mild.  In  the  report  of  the 
Metropolitan  Asylum's  Board  Hospitals  mild  as  well  as  mori- 
bund cases  were  not  injected.  As  regards  the  influence  of  bac- 
teriologic diagnosis  it  is  a  fact  which  no  one  acquainted  with 
will  dispute  that  the  number  of  cases  which  would  formerly  have 
been  considered  diphtheria,  but  which  are  now  excluded  from 
the  statistics  by  bacteriologic  irtvescigation,  far  exceed  those  in 
which  the  reverse  is  true. 

While  the  above  are  strong  replies  to  the  criticisms  of  the  op- 
ponents of  antitoxin,  we  are  indebted  to  Park  for  a  table  of 
statistics  against  which  none  of  the  usual  objections  can  be  urged. 
This  table,  complied  from  the  official  records  of  Berlin,  Paris 
and  New  York,  shows  the  absolute  death  rate  per  100,000  in- 
habitants in  these  cities  from  diptheria  and  croup  from  1886  to 
1897  inclusive.  There  is  here  no  room  for  asserting  that  the 
statistics  have  been  twisted  to  favor  any  plan  of  treatment,  that 
any  special  class  of  cases  has  been  excluded  or  included, and  yet 
the  reduction  in  mortality  in  all  three  of  these  cities  since  the 
introduction  of  antitoxin  is  remarkable  and  too  uniform  to  be 
the  result  of  mere  coincidence.  This  table  is  of  such  interest 
that  it  is  here  appended: 


SOCIETY  REPORTS. 


157 


ABSOLUTE    DEATH    RATE    FROM    DIPHTHERIA    AND    CROUP    PER    100,000 
POPULATION. 


Year. 

Berlin. 

Paris. 

New  York. 

1886 

125.7 

100.7 
76.1 
85.6 

102.0 
67.5 
92.9 

100.8 
86.7 

t59.7 
30.9 
26.1 

73.2 

76.9 
83.7 
79.9 
77.5 
63.0 
6.3.6 
51.4 
40.7 
17.7 
17.6 
17.2 

187.5 
205.6 
167.7 
146.2 
110.6 
118.7 
123.3 
145.5 
158.5 
105.2 
91.3 
86.4 

1887 

1888  

1889 

1890 

1891         .     . 

1892 

1893       

1894 

1895 

1898 

*1897 

*Last  quarter  of  year  estimated. 
fGeneral  use  of  antitoxin  commenced. 

As  regards  actual  advances  in  the  antitoxin  treatment  of  diph- 
theria, the  chief  of  these  seems  to  be  the  production  of  more 
potent  and  trustworthy  serums  and  the  attention  to  details  in  its 
manufacture,  whereby,  its  efficacy  has  been  increased  and  many 
of  its  objectionable  features  diminished.  Rashes  and  joint  symp- 
toms following  its  use  are  now  somewhat  less  frequent  than 
formerly. 

The  preparation  of  dried  serum  has  not  yet  been  brought  to 
a  sufficient  degree  of  perfection  to  supplant  the  ordinary  pro- 
duct, while  "we  have  no  more  hope  than  we  had  five  years  ago 
of  separating  antitoxin  completly  from  the  horse  serum." 

During  the  past  few  months  the  Health  Department  of  New 
York  city  has  been  testing  the  comparative  frequency  of  rashes 
after  the  use  of  filtered  and  unfiltered  serums.  Your  committee 
is  indebted  to  Dr.  Wm.  L.  Somerset,  Resident  Physician  Wil- 
lard  Parker  Hospital,  for  the  following  statement,  which  is  an 
approximate  one,  of  the  results  obtained:  Previous  to  the  em- 
ployment of  filtered  serum,  rashes  occurred  at  the  Willard  Par- 
ker Hospital  in  from  25  to  30  per  cent,  of  all  cases:  since  the  use 
of  filtered  and  unfiltered  serum  in  parallel  cases,  the  percentage 
of  rashes  where  filtered  serum  was  injected  has  been  reduced  to 
about  15  percent.,  while  it  has  risen  to  about  40  percent,  where 
the  unfiltered  product  was  employed.  The  higher  percentage 
of  rashes  in  the  latter  class  of  cases  than  formerly,  is  due  to  the 


j..g.  SOCIETY  REPORTS. 

fact  that  the  unfiltered  serum  used  In  these  cases  contained  the 
residue  from  the  filtered  portion.  It  would  thus  appear  that 
the  production  of  rashes  is  caused  largely  by  some  constituent 
of  the  serum  which  is  incapable  of  passing,  or  passes  only  in 
small  amounts,  through  unglazed  porcelain. 

The  use  of  antitoxin  as  a  prophylatic  measure  has  been  steadily 
gaining  ground, and  with  the  production  of  a  serum  from  which 
all  objectionable  features  have  been  elimirrated,  its  use  in  this 
direction  will  doubtless  become  even  more  popular;  though, 
from  the  temporary  nature  of  the  immunity  affected,  it  must 
remain  a  measure  to  be  adopted  only  in  the  presence  of  epidem- 
ics or  in  cases  where  exposure  has  undoubtedly  occurred. 

YELLOW  FEVER 

In  1854  and  1855,  inoculation,  as  a  preventive  measure,  was 
made  use  of  in  Havana  during  an  epidemic  of  yellow  fever.  In 
1887,  this  idea  was  again  introduced  and  followed  up  very 
thoroughly  in  Brazil.  But  in  neither  instance  were  the  results 
satisfactory.  In  1S92,  Domingo  Freire  introduced  a  diluted 
virus  derived  from  the  microccus  xanthogenicus,  which  he  hel 
to  be  the  etiological  factor  in  the  development  of  yellow  fever. 
This  diluted  virus  was  advocated  as  a  preventive  inoculation  by 
Dr.  Belinger,  of  San  Francisco,  Dr.  J.  McFadden  Gaston,  of 
Atlanta,  and  others  during  1893  and  1894;  but  the  results  have 
been  disappointing.  About  the  same  time,  in  1863,  Dr.  A.  S. 
Ashmead  recommended  "Murray's  immunizing  method"  as  fol- 
lows: Inoculate  with  the  blood  serum  of  a  partially  immune  sub- 
ject (negro),  and  inoculate  a  second  time  with  perfectly  immune 
blood  serum  of  a  white  subject  who  has  had  yellow  fever.  Be- 
fore inoculation,  however,  as  frost  always  modifies  the  virus, 
let  the  infected  serum  be  first  exposed  to  frost.  Follow  at  once 
with  a  second  inoculation  of  immune  blood  serum. "  Disappoint- 
ments likewise  followed  the  use  of  this  method. 

In  July,  i8y7.  Prof.  G.  Sanarelli,  of  the  University  of  Monte- 
video, isolated  and  cultivated  a  bacillus  which  he  considers  to 
be  the  specific  organism  of  yellow  fever.  Probably  it  is  the 
same  bacillus  as  that  formerly  described  by  Surgeon  General 
Sternberg.  Possibly  both  may  ultimately  be  proven  to  be  sec- 
corda-y  invaders.  However,  Sanarelli  has  been  occupying  him- 
self since  last  summer  in  the  securing  of  a  protective  or  curative 
serum,  about  which  most  encouraging  reports  have  been  already 


SOCIETY  REPORTS.  j  -  q 

made.  And  yet  scarcely  is  the  hope  born  that  at  length  we  have 
a  protective  or  curative  agent  with  which  to  meet  yellow  fever 
before  adverse  reports  are  coming  in  to  indicate  that  we  must 
wait  and  see. 

TUBERCULOSIS. 

The  medical  world  was  startled  in  1890  by  the  announcement 
that  Koch  had  discovered  a  remedial  agent  for  phthisis.  This 
announcement  was  hailed  with  joy,  and  it  was  immediately  put 
to  the  clinical  test,  but  its  virtures,  so  ably  set  forth  by  its  dis- 
coverer, soon  began  to  minimize,and  finally  it  fell  into  disrepute 
as  a  curative  remedy.  Since  the  introduction  of  tuberculin 
several  serums  have  been  brought  forward,  and  have  been  tried 
with  varying  success  by  many  physicians. 

Among  the  most  popular  of  these  preparations  are  the  serum 
of  Prof.  E.  Laragliano,  of  Genoa,  obtained  from  the  dog,  the 
ass,  and  the  sheep.  When  treatment  was  begun  as  late  as  the 
formation  of  cavities  in  the  lungs,  he  claim  a  cure  of  7.76  per 
cent.  In  non-febrile  tuberculosis,  his  successes  have  amounted 
to  nearly  100  per  cent,  of  recoveries.  He  recommends  that  i 
c.  m.  of  the  serum  should  be  the  dose  injected  subcutaneously 
every  second  day.  In  febrile  forms,  the  dose  may  be  increased 
for  several  days — 5  to  8  days — to  5  and  even  10  cm.  Such  are 
the  contradictory  reports  as  '-egards  successful  use  of  Maraglia- 
no's  serum  by  different  doctors  that  it  is  difficult  to  come  to  a 
fixed  opinion  on  the  subject. 

What  has  been  said  in  general  of  Maraglino  serum  applies  in 
the  main  to  the  publi  hed  results  of  the  use  of  the  antitubercle 
serum  introduced  in  1895  by  Dr.  Paul  Paquin,  of  St,  Louis 
That  it  is  useful  when  administered  with  other  remedies  is  more 
than  probable. 

Early  in  1869,  Koch  introduced  what  he  called  T.  R.  Tuber- 
lin,  and  this  was  followed  by  encouraging  reports  of  its  use. 
But  it  was  not  long  before  the  process  of  its  manufacture  was 
found  to  be  faulty  in  that,  notwithstanding  the  centrifugation, 
it  was  discovered  that  in  a  large  number  of  the  preparations  on 
the  market  tubercle  bacilli  remained  in  the  fluid.  This  being 
recognized  as  an  error  of  manufacture,  it  has  been  withdrawn 
from  market — certainly  until  the  fault  of  its  manufacture  can  be 
remedied. 

Antiphthisin  is  a  sozalbumin,     ntroduced  some  years  ago  by 


jgQ  TRANSLATIONS  AND  FOREIGN  REVIEWS 

Klebs,  which  he  regards  as  the  germicidal  part  of  tuberculin. 
Von  Ruck  "attests  its  absolute  safety,  and  considers  that  it  has 
curative  properties." 

But  the  early  disappointments  in  practice  of  the  serum  treat- 
ment of  tuberculosis  have  made  the  profession  skeptical  as  to 
the  remunerative  value  of  any  and  all  such  methods  of  treatment ; 
and  yet  it  is  evident  to  the  non-skeptical  who  reviews  the  experi- 
ence of  unbiased  practitioners  that  it  is  probable  that  whatever 
may  be  found  curative  of  tuberculosis,  one  of  the  measures  to  be 
used  will  be  perfection  of  some  of  the  antitoxines  so  called.  It 
is  the  opinion  of  many  that  the  scientific  worker  is  getting  in 
the  neighborhood  of  the  real  remedy,  and  is  probably  knocking 
at  the  door  of  the  house  in  which  the  truth  is  to  be  found. 


XTranelatione  anb  jforeiGn  1Revlew6. 


IN   CHARGE  OF 

Richard  H.  Whitehead,   M.D.,  Chapel  Hill,  N.   C. 


Koch's  New  Tuberculin. — Undaunted  by  the  lamentable 
failure  of  his  tuberculin  the  famous  bacteriologist,  Robert 
Koch,  has  offered  us  a  new  preparation  for  the  treatment  of 
tuberculosis  {Deutsches  Med.  Wochenschrift,  No.  14,  1897).  The 
reasoning  which  led  up  to  this  preparation  and  the  method  of 
its  production  are  briefly  as  follows:  Immunity  from  infectious 
diseases  may  be  conferred  in  at  least  two  ways.  In  one  case 
the  immunity  is  produced  by  injections  in  increasing  doses  of  the 
specific  toxin  of  the  disease.  The  immunity  thus  conferred 
does  not,  however,  necessarily  interfere  with  the  growth  of  the 
specific  bacterium,  but  simply  prevents  symptoms  due  to  its 
specific  toxin.  It  may,  therefore,  be  called  toxin-immunity. 
Tetanus  offers  an  illustration.  In  the  second  case  the  immun- 
ity is  bactericidal  in  nature.  For  example  animals  may  be  ren- 
dered immune  to  cholera  and  typhoid  fever  by  R.  Pfeififer's 
method  of  innoculating  the  living  germs  of  those  diseases.  The 
germs  iniroduced  into  the  bodies  of  animals  thus  rendered  im- 
mune, rapidly  die  and  yet  such  animals  are  almost  as  susceptible 


TRANSLATION  OF  FOREIGN  REVIEWS-  j  6  j 

as  ever  to  the  toxins  of  these  diseases.  This  we  may  call  bac- 
terial-immunity. The  agents  which  produce  this  form  of  im- 
munity are  integral  parts  of  the  bodies  of  the  bacteria  and  are 
set  free  when  the  latter  die  and  disintegrate.  Immunity  to  be 
■complete,  he  says,  must  combine  both  of  these  forms:  To  ob 
tain  this  he  has  been  workmg  for  six  years,  and  he  believes  with 
success  at  last.  His  attempts  to  confer  immunity  by  innoculat- 
ing  the  dead  bodies  of  the  bacilli  were  in  vain.  If  injected  sub- 
cutaneously  they  are  not  absorbed  with  sufficient  rapidity  and 
produce  abscesses.  If  brought  directly  into  the  circulation  they 
produce  tubercles.  Accordingly,  he  dried  agar  cultures  of  the 
bacilli,  and  pulverized  these  in  a  mortar.  To  this  triturate  he 
added  distilled  water  and  centrifugalized  the  mixture.  This 
separates  into  a  liquid  above  and  a  precipitate  below.  The 
latter  contains  the  powdered  bodies  of  the  bacilli  and,  with  a 
little  working  over,  is  the  new  tuberculin.  With  this  he  could 
always  confer  immunity  to  tuberculosis  upon  laboratory  animals, 
and  could  always  cure  tuberculosis  in  such  animals,  provided 
the  treatment  was  begun  early.  He  also  treated  a  number  of 
human  patients  and  of  the  result  he  says  modestly:  "I  ob- 
tained marked  improvement  in  every  case.  I  use  word  'im- 
provement' intentionally,  although,  according  to  the  usual  con- 
ception, not  a  few  of  the  cases  would  have  been  classed  as  cured. 
However,  I  consider  it  premature  to  speak  of  cures  unt  1  suffi- 
cient time  has  passed  without  relapse."  Since  this  communica- 
tion the  treatment  has  been  tried  in  true  scientific  spirit  by 
numerous  competent  observers,  and  with  the  absence  of  the 
sensationalism  which  attended  the  introduction  of  the  old  tuber- 
culin. Of  the  reports  which  have  bee»  presented  in  subsequent 
numbers  of  the  Wochenschrift,  the  following  are  fair  examples : 
Bussemius,  of  Berlin,  treated  fifteen  cases.  With  the  excep- 
tion of  two  cases  of  lupus  he  could  observe  no  material  im- 
provement. Professor  Schultze,  of  Bonn,  in  nine  cases  could 
not  attribute  any  effect  to  the  tuberculin,  favorable  or  otherwise. 
Doutrelepont,  of  Bonn,  treated  fifteen  cases  of  lupus  in  five  of 
which  the  ulcers  cicatrized.  He  expresses  the  opinion  that  the 
new  preparation  is  an  improvement  over  the  old  one  in  the 
treatment  of  lupus.  Leick,  of  Greifswald,  could  not  observe 
any  favorable  effect  upon  fifteen   cases   of  pulmonary   tubercu- 


jg2  TRANSLATION  OF  FOREIGN  REVIEWS. 

losis.  The  results  of  Professor  Rumpt,  of  Hamburg,  in  twelve 
cases  were  by  no  means  brilliant.  Herzfeld  in  seven  cases  of 
laryngeal  tuberculosis  saw  only  one  improve.  Baudach  treated 
twelve  cases  in  a  sanatorium,  and  thought  all  improved  more 
than  they  would  on  hygienic  treatment  alone.  At  present  the 
journals  seem  inclined  to  let  the  subject  drop  and  await  further 
developments.  Perhaps  it  is  too  soon  yet  to  form  positive  opin- 
ions as  to  the  merit  of  the  new  tuberculin  but  if  v/e  are  to  judge 
by  the  evidence  so  far  presented  it  is  no  material  improvement 
on  its  unfortunate  predecessor. 

Picric  Acid  in  the  Treatment  of  Burns. — In  view  of  the 
face  that  a  great  deal  of  praise  has  been  bestowed  upon  picric 
acid  as  a  local  application  for  burns,  it  is  well  to  note  that  the 
use  of  this  drug  may  be  attended  by  serious  inconveniences. 
Latouche  (Semaine  Medicale,  No.  5,  1898),  reported  to  the 
Surgical  Society  of  Paris  two  cases  of  poisoning  by  picric  acid. 
Both  patients  were  children  treated  for  burns  of  the  face  and 
hands  by  local  application  of  saturated  aqueous  solutions  of  the 
acid.  The  application  caused  great  pain  followed  by  repeated 
vomiting  and  diarrhoea.  The  skin  and  scleroties  were  colored 
yellow  and  the  urine  contained  large  quantities  of  picric  acid. 
One  of  the  children  was  quite  ill  for  a  week,  but  both  recovered. 

In  the  discussion  which  followed  numerous  surgeons  stated 
that  they  had  had  similar  experiences. 

Dr.  Schlatter's  Removal  of  the  Stomach. — Recently  the 
newspapers  have  been  publishing  reports,  rather  sensational  in 
character,  of  this  operation.  It  may  be  interesting  to  review 
the  Swiss  surgeons  own  account  of  it.  The  operation  was 
undertaken  to  relieve  symptoms  of  obstruction  at  the  pylorus, 
but  finding  that  the  stomach  was  the  seat  of  diffuse  cancer  ex- 
tending from  end  to  end,  he  determined  to  excise  the  entire 
organ.  He  accordingly  ligated  and  divided  the  greater  and 
lesser  omentum,  and  then  cut  away  the  stomach  from  the  deode- 
num  and  oesophagus.  It  was  impossible  to  approximate  the 
deodenum  and  oesophagus, so  he  closed  the  open  end  of  the  latter 
and  bringing  up  a  loop  of  jejunum  over  the  transverse  colon 
anastomosed  it  to  the  oesophagus.  The  patient,  a  woman  aged 
56,  made  a  smooth  recovery. 


THE  MEDICAL  TREATMENT  OF  GOITRE.  1 63 

Under  date  of  January  loth,  Schlatter  stated  that  his  patient 
was  still  kept  in  the  Zurich  clinic  for  study,  that  she  continued 
well,  and  has  gained — four  months  after  the  operation — over 
10  pounds. — Semaine  Medical  ViO.  4,   1898. 

[The  operation  has  recently  been  done  twice  by  American 
surgeons,  with  promptly  fatal  results.] 


The  Medical  Treatment  of  Goitre. — In  view  of  the  ineffi- 
ciency of  medical  agents  in  the  treatment  of  simple  goitre,  this 
affection  came  gradually  to  be  recognized  as  a  surgical  disease. 
Yet  while  numerous  cases  have  been  cured  or  greatly  improved 
by  surgical  measures,  the  various  operations  employed  are  at- 
tended with  more  or  less  risk  of  life  even  in  the  hands  of  ex- 
pert operators  and  are  sometimes  followed  by  serious  sequelae 
as  operative  myxoedema.  The  demonstration  of  the  fact  that 
many  of  these  cases  can  be  ameliorated  or  even  cured  by  thy- 
roid feeding  has  again  given  an  impetus  to  the  medical  treat- 
ment of  goitre.  As  the  thyroid  preparations  in  use,  however, 
vary  greatly  in  their  content  of  active  ingredient,  the  results 
derived  from  their  administration  have  lacked  uniformity.  Now, 
that  the  active  principle  of  the  thyroid  gland  has  been  isolated 
by  Prof.  Baumann,  and  presented  to  the  profession  in  the  form 
of  a  trituration  with  sugar  of  milk  under  the  name  of  iodothy- 
rine,  it  will  be  possible  to  obtain  the  full  advantages  of  the  thy- 
roid treatment. 

This  statement  is  borne  out  by  the  favorable  results  already 
secured  from  the  use  of  iodothyrine  in  cases  of  goitre,  and  this 
remedy  appears  to  be  a  valuable  addition  to  the  medical  resources 
of  the  physicians  in  the  management  of  this  disease,  especially 
in  its  earlier  stage. 


When   writing  to  advertisers  please  mention  this  Journal. 


NORTH  CAROLINA  MEDICAL  JOURNAL, 

ROBERT  D.  JEWETT,  M.D.,  Editor. 


DEPARTMENT  EDITORS. 

(      H.  T.  Bahnson,  M.D.,  Salem.  N.C. 
SURGERY:     \     R.  L.  Gibbon, M.D.,  Charlotte,  N.  C. 

(      J.  Howell  W  ay,  M.D.,  Waynesville,  N.  C. 

NERVOUS  DISEASES:— J  .llison  Hodges,  M.D.,  Rcihmond,  Va. 
PRACTICE  OF  MEDICINE.  \    ^-  ^S^^^^nTe^Tc'.  "'•''•'  ^'  ^*  ""■ 


OBSTETRICS: 


George  G.  Thomas,  M.D.,  Wilmington,  N.  C, 
R.  L.  Payne,  M.D.,  Norfolk,  Va. 


(      H.  S.  LOTT,  M.D.,  WinBton.  N.  C. 
GYNECOLOGY:     \     J.  W.  Long,  M.D.,  Salisbury,  N.  C. 
(      H.  A.  ROYSTER,  M.D.,  Raleigh,  N.  C. 

PATHOLOGY:— Albert  Anderson,  M.D.,  Wilson,  N.  C. 
PEDIATRICS:— J.  W.  P.  Smithwick,  M.D.,  La  Grange,  N.  C. 
TRANSLATION  AND  FOREIGN  REVIEWS: 
Richard  H.  Whitehead,  M.  D.  ,  Chapel  Hill,  N.  C. 

This  Journal  is  published  on  the  fifth  and  twentieth  of  each  month,  and 
any  subscriber  tailing  to  receive  his  copy  promptly,  is  asked  to  announce  the 
fact  to  this  office. 

Cuts  will  be  provided  for  any  original  communications  (sent  to  this  Jour- 
nal only)  requiring  illustrations,  free  of  cost  to  ihe  author. 

Secretaries  of  County  Medical  Societies  in  the  Carolinas  are  asked  to 
furnish  condensed  reports  of  their  meetings  to  the  Journal. 

All  communications,  either  of  a  literary  or  business  nature,  should  be 
addressed  to,  and  any  remittances  by  P.  O.  Order,  Draft  or  Registered  Let- 
ter, made  payable  to  Robert  D.  Jewett,  M.D.,  P.  O.  Drawer  825,  Wilming- 
ton, N.  C. 

fiMtotiaL 


REMOVAL  NOTICE. 


After  the  mailing  of  this  issue  the  office  of  publication 
of  the  North  Carolina  Medical  Journal  will  be  trans- 
ferred from  Wilmington  to  Winston,  N.  C,  to  which  address 
all  communications  should  in  future  be  directed.       The  "Twin 


REVIEWS  AND  BOOK  NOTICES.  I^c 

Cities"  of  North  Carolina  (Winston-Salem)  are  situated  in  the 
piedmont  section  of  the  State,  and  in  the  great  tobacco  growing 
region.  They  are  surrounded  by  productive  farms  and  indus- 
trious farmers,  and  under  the  influence  of  these  and  diversified 
manufacturing  enterprises,  which  are  constantly  on  the  increase, 
these  cities  (virtually  one)  are  pushing  rapidly  to  the  front. 

While  it  must  be  with  a  feeling  akin  to  sadness  that  the  friends 
of  the  Journal  see  it  removed  from  the  place  of  its  birth,  they 
will  realize  that  it  is  an  evidence  of  the  spirit  of  progress,  which 
has  marked  the  course  of  the  present  management,  that  the  Jour 
NAL  having  reached  its  maiority  must  strike  out  on  broader 
lines.  There  will  be  no  change  in  the  interests  or  management 
of  the  Journal,  but  with  the  improvements  maugurated  with 
the  present  year  and  to  come,  we  hope  to  give  to  our  readers  a 
truly  dignified,  ethical  and  up-to-date  journal,  reflecting  from 
its  pages  the  best  medical  thought  ot  this  and  foreign  countries, 
and  especially  to  make  it  a  worthy  medium  through  which  the 
profession  of  North  Carolina,  and  the  South  generally,  may 
give  to  the  v/orld  the  benefits  of  their  thought  and  experience. 


TReviews  anb  IBooU  IRoticee. 

Flint's  Medical  and  Surgical  Directory  of  the  United  States 

and  Canada.  Issued  annually.  1S97.  Complied  by  A.  L.  Chatterton.  J, 
B.  Flint  &  Co.,  New  York,   1S97. 

After  several  months  use  of  this  directory  we  find  it  the  most 
accurate  of  any  list  of  physicians  with  which  we  have  met.  It 
gives  the  names  of  1543  physicians  in  North  Carolina  and  there 
appear  very  lew  errors. 

Lectures  on  the  Action  of  Medictties.— Being  the  Course  of 

Lectures  on  Pharmacology  and  Therapeutics,  delivered  at  St.  Bartholomew's 
Hospital  during  the  Summer  Session  of  1896.  By  T.  Lauder  Brunton.M.  D,, 
D.  Sc.  (Edin),  LL.  D.,  (Hon.)  (Aberd.)  F.  R.  S.  Octavo,  674  pages,  Cloth 
$4.00.     The  Macmillan  Company,  New  York,  1897. 

This  volume  comprises  thirty-five  lectures  which  were  deliver- 
ed without  manuscript  and  stenographically  reported.  It  was 
the  author's  aim,  so  he  says  in  a  prefatory  note,  to  give  his  stu- 


J  5^  OBSTETRICS. 

dents  only  SO  much  in  these  lectures  as  they  could  assimilate. 
Their  use  is  not  to  supply  the  student  with  all  the  information 
he  needs,  "but  to  awaken  his  attention,  to  excite  his  interest,  to 
impress  upon  him  certain  points  which  will  form  a  neucleus  for 
his  knowledge,and  around  which  he  may  afterwards  group  more 
information."  Dr.  Brunton  is  not  a  believer  in  the  method  of 
cramming,  a  method  two  often  adopted  by  those  preparing  for 
examinations.  The  lectures  are  not  arranged  after  any  cut  and 
dried  system  and  each  drug  in  the  pharmacopea  minutely  stud- 
ied as  to  its  physiologic  action,  but  are  made  interesting  dis- 
courses in  which  the  general  action  of  groups  of  remedies  are 
considered  as  they  affect  certain  organs  or  conditions.  Fre- 
quently the  most  important  member  of  a  certain  group  is  studied 
more  closely. 

The  volume  is  one  that  can  be  read  by  one  with  interest  for 
hours  at  a  time,  and  the  subject  matter  is  so  interspersed  with 
personal  experience  of  the  author  that  the  important  points  are 
more  firmly  fixed  in  the  reader's  mind. 

The  paper,  binding  and  typography  are  excellent. 


IRcvlcvo  of  Current  Xiterature. 


OBSTETRICS. 

in  charge  of 

Geo.  Gillett  Thomas,  M.  D.,  R.  L.  Payne,  M.  D., 


A  Case  OF  Combined  Intra  and  Extra  •  Uterine  Pregnancy 
AT  Term.— In  a  reprint  from  a  recent  number  of  the  American  .Journal 
of  Obstetrics  Dr.  Hubert  A.  Royster,  of 'Raleigh,  N.  C,  details  the 
following-  remarkable  case: 

Juanita  D.  aet.  34  years  multipara  was  attended  in  her  seventh  con- 
finement June  27,  '97,  by  a  negro  midwife.  A  living  child  was  deliv- 
ered and  forty-eight  hours  later  Dr.  Powers  was  called  in  because  the 
midwife  "felt  another  child  and  it  wouldn't  come."  The  doctor  diag- 
nosed abdominal  pregnancy  at  term  and  advised  operation.  This  was 
refused.     Later  several  competent  physicians  saw  the  patient  and  con- 


OBSTETRICS.  l6y 

firmed  the  diagnosis  but  operation  was  declined.  On  July  15th  patient 
was  seen  by  Dr.  Royster  in  consultation  with  Drs.  Powers  and  Harris. 
The  doctor  obtained  the  following  history  of  her  gestation:  "She 
menstruated  last  in  the  early  part  of  October  1896,  (exact  date  not  re- 
membered) and  seemed  to  be  normally  pregnant  up  to  the  4th  of  Decem- 
ber. On  the  evening  of  that  day,  just  before  retiring,  she  went  out  in 
the  yard,  squatted  down  on  the  ground  to  urinate  and  while  in  the  act 
was  seized  with  sudden  sharp  pain  in  the  right  side  which  caused  her 
to  call  for  help.  She  fell  in  a  half  fainting  way,  was  carried  into  the 
house  put  to  bed  and  in  a  few  hours  recovered.  There  was  no  external 
loss  of  blood.  Her  abdomen,  however,  became  larger  and  she  has 
"never  felt  right  since,  being  in  bed  a  part  of  the  time  up  to  a  week 
before  her  confinement. ' ' 

Atthetime  of  Dr.  Royster's  writing  nothing  definitecould  be  made  out 
The  abdomen  was  so  "slightly  distended  that  palpation  and  percus- 
sion revealed  nothing  save  the  presence  of  fluid  extending  almost  up 
to  the  xiphoid  cartilage  and  showing  distinct  uniform  fluctuation. 
There  was  dullness  anteriorly  and  resonance  in  the  flanks.  ^  *  * 
Slight  pressure  produced  acute  pain.  *  *  *  The  cervix  was  large, 
boggy  and  deeply  lacerated;  there  was  a  rusty-colored  odorless,  sticky 
discharge  from  the  uterus.  Her  temperature  was  101*  degrees  and  her 
pulse  120."  She  was  bi-ought  into  Rex  Hospital  July  17th  with  a  tem- 
perature of  103  degrees  and  a  pulse  of  128,  and  preparation  immedi- 
ately begun  for  operation.  Operation  was  done  on  the  18th  by  Dr. 
Royster,  assisted  by  Drs.  Goodwin,  Knox,  McGeachy,  W.  I.  Royster, 
Harris  and  Powers.  After  ansesthetization  patient  was  placed  on  the 
table  in  the  Trendelenburg  position  and  the  abdomen  opened  by  a  four- 
inch  median  incision.  The  abdominal  walls  were  thinned  by  overdis- 
tention  and  the  knife  at  once  came  down  on  thickened  peritoneal  tissue. 
Cutting  through  this,  a  large  quantity — probably  a  half  gallon — of 
dirty,  yellowish  fluid  of  a  peculiar  odor  began  to  gush  out.  When 
almost  all  of  this  had  been  allowed  to  escape  the  incission  was  pro- 
longed with  scissors  and  the  left  hand  introduced.  The  lower  extremity 
of  a  fetus  was  felt  and  a  knee  brought  up  into  the  wound,  demonstrat- 
ing the  correctness  of  Dr.  Power's  diagnosis. 

The  incision  was  again  prolonged,  making  it  seven  inches  in  length. 
Grasping  the  dead  child  by  the  head  and  shoulders,  I  delivered  it 
through  the  incision,  tied  the  cord  and  cut  it  close  to  the  fetus .  To 
save  time  only  one  ligature  was  used.  Preparations  were  now  made 
to  deal  with  the  placenta,  It  was  found  in  the  lower  part  of  the  cavity, 
mainly  to  the  left  of  the  middle  line,  though  extending  somewhat  to 
the  right.  It  was  adherent  to  the  anterior  abdominal  wall  and  to  the 
left  side  of  the  pelvic  brim.  The  umbilical  cord,  short  and  thick,  was 
adherent  to  the  anterior  wall  at  two  points  to  the  right  of  the  incision, 
but  it  was  separated  easily  and  traced  up  to  its  placental  attachment. 
Before  attempting  to  enucleate  the  placenta  a  careful  examination  was 
made,  in  order  to  determine  if  there  had  been  a  rupture  of  the  uterus. 


1 68 


OBSTETRICS, 


In  doing  this  it  was  seen  that  the  gestation  sac  was  entirely  extraperi- 
toneal, and  that  the  general  cavity  of  the  abdomen  had  not  been  opened 
except  for  two  inshes  at  the  upper  angle  of  the  incision,  where  it  had 
been  prolonged  to  gain  room  for  extracting  the  child.  This  opening 
had  already  been  covered  by  gauze  pads,  and  the  position  of  the  patient 
prevented  protrusion  of  the  bowel.  The  sac,  being  tightly  fixed  to  the 
anterior  abdominal  wall,  was  in  front  of  and  below  the  intestines, 
while  the  uterus  and  its  appendages  were  in  their  nonnal  situation 
below  and  behind.  In  order  to  make  sure  of  the  condition  of  the 
uterus,  one  of  my  assistants  introduced  his  left  hand  into  the  al- 
ready disinfected  vagina,  and,  manipulating  with  the  other  hand 
above,  found  this  organ  whole  and  in  good  position,  the  gesta- 
tion sac  growing  fast  to  its  left  cornu.  The  placenta  was  now  gently 
loosened  by  dry  dissection,  and  its  coverings  stripped  back  by  the 
fingers  until  the  left  wall  of  the  pelvis  was  reached,  where  two  silk  lig- 
atures were  placed  around  the  more  vascular  adhesions  and  the  tissues 
cut  on  the  placental  side.  There  was  very  little  bleeding.  The  sac  was 
cleared  of  its  debris  of  slimy,  macerated  material,  washed  out  with 
hot  salt  solution,  sponged  ary,  and  the  abdominal  wound  closed  with 
through-and-through  silkworm-gut  sutures,  after  inserting  stx'ips  of 
gauze  and  bringing  their  ends  out  through  the  lower  angle  of  the  incis- 
ion for  drainage.  The  abdomen  was  dressed  with  sterilized  gauze  and 
cotton  retained  by  a  flannel  binder.  The  patient  was  put  to  bed  and 
exhibited  not  a  sign  of  shock.  She  had  no  vomiting  or  nausea  and 
her  pulse  was  104. 

The  after  history  of  the  case  was  uneventful  the  patient  going  on 
steadily  to  convalescence.  She  rapidly  regained  flesh  and  strength 
and  was  discharged  from  hospital  August  27th  in  perfect  health.  The 
extra-uterine  fetus  was  a  fully  developed  female  weighing  four  and  a 
quarter  pounds.     The  placenta  v/eighed  two  pounds. 

[This  case  is  not  only  of  interest  because  of  the  skill  with  which  it 
was  treated  by  Dr.  Royster  but  because  of  its  rarity.  Very  few  cases 
of  ectopic  gestation  go  on  to  term,  death  of  the  fetus  usually  occurring 
at  an  early  date,  because  of  the  imperfect  development  of  the  maternal 
side  of  the  placenta;  and  very  much  rarer  are  cases  of  extra  and  intra- 
uterine pregnancy  reaching  term.  Another  point  of  interest  attaching 
to  the  case  is  that  at  the  time  ot  the  escape  of  the  fetus  into  the  abdom- 
inal cavity  (December  4th)  there  probably  occurred  a  tubal  abortion 
and  the  ovum  was  simply  expelled  from  the  fimbriated  extremity  of 
the  tube  without  rupture  of  the  sac.  The  reasons  for  thinking  this  are 
the  time  at  which  this  accident  occurred,  prior  to  the  usual  period  of 
closure  of  the  fimbriated  end  of  the  tube  and  the  slight  evidence  of 
shock  and  hemorrhage  attending  the  accident.  The  patient  "was 
seized  with  sudden  sharp  pain  in  the  right  side.  *****  gj^^ 
fell  in  a  half  fainting  way,  was  carried  into  the  house,  put  to  bed,  and 
in  a  few  hours  recovered."  A  very  different  state  of  affairs  from  the 
intense  shock  and  exsanguined   appearance    that   usually  attends  the 


PEDIATRICS.  l6g 

rupture  of  an  ectopic  pregnancy  and  yet  there  is  little  doubt  that  these 
symptoms  were  caused  by  the  escape  of  the  product  of  conception  into 
the  abdominal  cavity  and  the  fact  that  the  ovum  was  probably  dropped 
from  the  mouth  of  the  tube  entire  is  no  doubt  a  principal  factor  in  its 
continued  growth  and  in  its  ultimately  I'caching  full  term.  ]        R.  L.  P. 


PEDIATRICS. 

IN   CHARGE   OF 

J.  W.  P.  Smithwick,  M.  D.,  LaGrange,  N.  C. 


A  New  Factor  in  the  Aetiology  of  the  Digestive  Diseases 
OF  Early  Childhood.— Sonnenberger  claims  that  in  the  production 
of  the  diseases  of  digestion  of  early  childhood,  the  factors  are  to  be 
looked  upon  as  forms  of  intoxications  which  arise  at  one  time  from 
bacterial  toxines,  at  another  from  vegetable  alkaloids  and  similar 
matters,  which  have  contaminated  the  milk  through  the  food  of  the 
animal  from  which  it  is  obtained.  The  child's  stomach  is  loaded  with 
milk  containing  these  toxins  or  alkaloids,  which  it  is  unable  to  render 
aseptic  on  account  of  the  small  quantity  of  hydrochloric  acid  present. 
These  enter  the  intestinal  canal,  and  through  absorption,  we  obtain, 
according  to  the  variety  and  intensity  of  the  poisons,  more  or  less 
symptoms  of  intoxication,  (vomiting,  diarrhaea,  collapse,  etc).  He 
admits  that  the  heat  of  the  summer,  and  bad  sanitary  conditions  are 
equally  responsible  for  these  diseases,  but  gives  special  emphasis  to 
the  causative  relation  of  the  vegetable  alkaloids. 

He  gives  the  prophylaxis  in  a  nut-shell  by  saying,  "Avoid  the  poisons, 
and  the  breeders  of  the  poisoHS."  Sterilization  only  destroys  the 
living  bacteria,  but  does  not  influence  the  toxines  already  formed,  nor 
the  vegetable  poisons  present  in  the  milk;  therefore,  besides  being  care- 
ful as  to  its  sterilization,  we  should  direct  our  attention  to  the  rational 
feeding  of  the  animals,  and  exclude  all  food  containing  vegetable 
poisons. 

Goats'  Milk  in  the  Treatment  of  Athrepsia.— Dr.  W.  Thorn- 
ton Parker  (Pediatrics,  Vol.  5,  No.  3),  claims  that  goats'  milk  is  the 
best  food  for  infants  when  they  have  to  be  fed  artificially.  It  is  more 
readily  digested  and  seems  to  be  better  adapted  to  the  wants  of  the  in- 
fants than  that  of  a  cow.  Furthermore,  the  goat  is  a  hardy,  healthy 
animal,  never  subject  to  tuberculosis,  and  for  this  one  great  reason, 
should  merit  our  careful  consideration.  We  all  know  how  difficult  it 
often  is  for  us  to  use  cows'  milk  in  the  feeding  of  infants,  and  he  claims 


,„Q  NOTES   AND  ITEMS. 

that  there  is  no  record  in  which  any  evil  results  could  be  attributed  to 
the  milk  of  the  goat. 

The  Treatment  of  Crusto  Lactea.— Dr.  W.  P.  Kisler  (Medical 
Record,  Vol.  53,  No.  7),  states  that  there  are  three  chief  indications  to 
be  fulfilled  in  attempting  to  cure  this  complaint,  viz.:  elimination,  pal- 
liation of  local  distress,  and  correction  of  malassimilatiou  and  resto- 
ration of  strength.  For  elimination  calomel  is  recommended  in  purga- 
tive doses  in  the  form  of  tablet  triturates,  the  dose  to  be  repeated  as 
the  conditions  may  indicate  to  obtain  a  perfect  clearance  of  the  stomach 
and  bowels.  To  alleviate  local  disti'ess,  the  benzoinated  oxide-of-zine 
ointment  is  a  good  application,  as  is  the  following  prescription: 

R— Salicylic  acid 2  parts. 

Bismuth  subnitrate 40     " 

Cornstarch 15     " 

Ointment  of  rosewater 100     ' ' 

Tliese  ointments  should  be  spread  thickly  on  pieces  of  muslin  and  ap- 
plied, and  these  applications  repeated  until  a  thick,  white,  and  rather 
dry  coating  forms  upon  the  surface  of  the  skin,  which  greatly  lessens 
the  itching  and  redness,  and  allows  a  healthy  epidermis  to  form. 
Soap  and  water  are  powerful  agents  to  aggravate  the  existing  inflam- 
mation, and  frequent  washing  a  child  affected  with  eczema  is  to  be 
strenuously  interdicted.  The  best  agents,  in  the  thirfl  indication,  are 
arsenic  in  the  form  of  Fowler's  solution  in  doses  suitable  to  the  age, 
and  the  ammoniated  citrate  of  iron,  which  should  always  be  combined 
in  the  treatment.     The  hygiene  and  diet  must  not  be  neglected. 


IRotes  anb  Items. 


Dr.  Virginius  Harrison's  office,  in  this  city,  was  the  scene  of  a 
brutal  assault  upon  the  doctor's  brother-in-law  by  a  disguised 
tramp,  who,  with  drawn  pistol,  demanded  money.  But  for  the 
coolness  and  determination  of  Mr.  Gordon,  the  gentleman  at- 
tacked and  mistaken  for  the  doctor,  he  might  have  been  killed. 
The  tramp  was  forcibly  ejected  from  the  door  and  thrown  violent- 
ly to  the  ground.  Before  an  ottcer  could  be  summoned  he  made 
his  escape.  This  attack  is  somewhat  similar  to  the  one  made 
by  foot-pads  upon  Dr.  Moyer,  of  Chicago,  a  few  days  ago. 
Tramps  evidently  believe  physicians  carry  money. — Richmond 
Jour,  of  Practice. 

"Filter  the  Water." — The  Philadelphia  Medical  Journal 
makes  the  following  plea  for  a  better  supply  of  drinking  water: 


KOTES  AND  ITEMS.  j  >,  j 

< 'London  has  a  death-rate  a  fraction  of  that  which  we  suffer. 
Why?  Because  she  has  common-sense  enough  to  filter  the  water, 
originally  filthier  than  ours,  which  she  uses.  While  our  bosses 
and  politicians  are  'feathering  their  own  nests, 'annexing  Hawaii, 
and  kicking  up  a  fuss  with  foreign  countries, they  have  not  time 
to  attend  to  the  health  of  the  people  whom  they  misrepresent — 
and  the  murdered  people  meekly  die, and  the  friends  of  the  dead 
continue  to  vote  for  the  bosses  and  their  henchmen." 

Chinese  Edition  of  Gray's  Anatomy. — Dr.  H.  T.  Whitney, 
President  of  the  Medical  Missionary  Association  of  China,  is 
engaged  in  translating  Gray's  Anatomy  into  Chinese. 

Dr.  James  M.  Parrott,  of  Kinston,  N.  C.  has  recently  left 
home  for  a  European  trip. 

Cheap  Instruments. — We  call  especial  attention  to  the  new 
advertisement  of  Messrs  Bartlett,  Garvens&Co.,  in  this  issue. 
They  are  offering  instruments  at  greatly  cut  rates.  In  writing 
them  don't  forget  to  mention  this  Joutnal,  please. 

A  Lemon  Grove  in  the  Intestine. — This  is  the  startling  head- 
ing of  a  communication  to  the  Med.  Record  ixom  Dr.  Rufus  D. 
Mason.  The  case  was  a  boy,  aged  6  years,  who  presented  symp- 
toms of  appendicitis.  However  a  few  doses  of  calomel  and 
epsom  salts  succeeded  in  bringing  away  numerous  lemon  seeds, 
some  of  which  had  sprouts  an  eighth  of  an  inch  long.  They  had 
been  in  the  intestine  fully  two  weeks.  Not  so  very  remarkable 
after  all. 

Elmer  L  Gates  of  Washington  is  said  to  have  devised  a  mic- 
roscope that  is  destined  to  revolutionize  microscopy.  It  is  said 
that  its  magnifying  power  exceeds  the  present  microscope  as 
much  as  the  latter  exceeds  the  naked  eye;  that  it  has  readily 
magnified  3,000,000  diameters,  and  by  increasing  the  power  of 
the  objectives  images  will  ultimately  attain  a  magnification  of. 
100,000,000  diameters. — Md.  Med.  Jour. 

Mkdical  Partners  Jointly  Responsible. — A  case  is  mention- 
ed in  the  Inter)iatio?ial  Medical  Magazine  in  which  a  father  and 
son  were  practising  medicine  as  partners.  The  son  was  called 
to  treat  a  fractured  arm  but  from  a  combination  of  ignorance  and 


J  y  2  BEADING  NOTICES. 

neglect  there  was  abaci  result.  Suit  was  brought  against  the 
firm  and  the  father  held  responsible  as  well  as  the  son,  though 
the  former  did  not  see  the  case  until  long  after  it  happen  d. 
This  joint  responsibility  will  be  a  matter  for  physicians  to  con- 
sider in  forming  partnerships. 

The  Buzzard  in  Medicine. — Dr.  Eugene  Street  suggests  that 
as  the  buzzard  seems  to  be  immune  to  disease  ptomaines  and 
toxines,  possibly  a  valuable  antitoxic  principle  may  be  obtained 
from  its  blood.  {N.  Y.  Med. .News.')  It  seems  to  us  that  it 
would  be  necessary  to  determine  first  whether  the  digestive 
organs  of  the  buzzard  may  not  neutralize  or  render  inert  all 
poisonous  substances,  in  which  case  it  is  possible  that  a  new 
general  germicide  may  be  obtained.  The  buzzard  should  cer- 
tainly be  studied  as  to  his  therapeutic  value. — Pediatrics. 


TReaMna  t^oticcs, 

Edw.  L.  H.  Barry,  Jr.,  M.  D.,  Jerseyville,  111.,  says:  I  have 
used  Aletris  Cordial  with  excellent  results  in  the  following:  Miss 
R.,  19  years  of  age,  brunette,  well-developed,  but^troubled  with 
dysmenorrhea,  called  at  my  office,and  after  explaining  herafiflic- 
tion  said,  "Doctor  if  there  is  any  thing  you  can  prescribe  to  re- 
lieve my  suffering  do  so,  for  life  is  a  burden  to  me  now."  I 
thought  of  the  Aletris  Cordial  at  once,  and  gave  her  a  six-ounce 
bottle,  directing  her  to  take  a  teaspoonful  three  times  a  day, 
commencing  four  or  five  days  before  the  regular  period.  Several 
weeks  afterward  she  returned  with  the  empty  bottle  remarking, 
"I've  come  back  for  more  of  that  medicine, for  it's  the  only  thing 
I  ever  had  to  give  me  relief."  I  can  cheerfully  recommend 
Aletris  Cordial  to  the  profession. 

The  preparations  of  "Pepsin,"  made  by  Robinson- Pettet  Co., 
are  endorsed  by  many  prominent  physicians.  We  recommend 
a  careful  p.erusal  of  the  advertisement  of  this  well-known  manu- 
facturing house.     (See  page  3) 

DOCTOR: — Your  library  is  not  complete  without  the  Hyp- 
notic Magazine.  Cost  of  this  handsome  monthly,  including 
premium  book  on  Suggestive  Therapeutics  is  only  one  dollar 
($1.00)  a  year. 

THE  PSYCHIC  PUBLISHING  CO., 
56  5th  Avenue,  Chicago.    , 


SYR,  HYPOPHOS.  CO.,  FELLOWS 

M^mi  the  Essential   Elemcntg  of  the  Animal  Organization— Potash  and  Lime; 
rilC  Oxidising  Agents — iron  and  Maganese: 

rhe  Tonics Quinine  and  Strychnine; 

hd  tlie  Vitalizing  Constituent — Phosphorus;  the '.^holecombined  in  the  form  of  aSyrupwith- 

Slightlv  All:alin_e  je^Qn;_ 
It  Differs  in  Its  Effects  from  all  Analoaas  Preparations;  and  it  possesses  the  important  properties 

—  Hill  II       nil  ■lliaiHIIIMIIIMIIIUIIIIJIIIMIIulril    M Jllll'    Ml   |||i»» m 

of  being  pleasant  to  the  taste,  easily  borne  by  the  stomach,  and  harmless  under  pro 
longed  Hse. 
ft  has   Gained  a  Wide   Reputation,  particularly  in  the  treatment  of  Pulmonary  Tuberculosis, 

Chronic  Bronchitis,   and  other  affections  of  the  respiratory  orgons.     It  has  also 

been  employed  with  much  success  in  various  nervous  and  debilitating  diseases, 
'tl  Cnratiye  Power   is  largely  attributable'  >  its  stimulant,  tonic,  and  nutritive  properties, 

by  means  of  which  the  energy  of  the  system  is  recruited. 
its  Action  is  Promptj  it  stimulates  the  appetite  and  the  digestion,  it  promotes  assimilation, 

and  it  enters  directly  into  the  circulation  with  the  food  products. 

The  prescribed  dose  produces  a  feeling  of  buoyancy,  and  removes  depression  and  mel- 
Micho ly ;  hence  the  preparation  is  of  great  value  in  the  treatment  of  mental  and  nervous 
ifcffections.  From  the  fact,  also,  that  it  exerts  a  double  tonic  influence,  and  induces  a 
y  flow  of  the  secretions,  its  use  is  indicated  in  a  wide  range  of  diseases. 


NOTICE-CAUTION. 

The  success  of  Fellows'  Syrup  of  Hypophosphites  has  tempted  certnin 
iDersons  to  offer  imitations  of  it  for  sale.  Mr.  Fellows,  who  has  examined 
lamplea  of  several  of  these,  finds  that  no  two  of  them  are  identical, 
jind  that  all  of  them  differ  from  the  original  in  composition,  in  freedom 
Tom  acid  reaction,  in  susceptibility  to  the  effects  o(  oxygen  when  ex- 
soaedto  light  or  heat,  in  the  property  of  retaining  the  Btryoh- 

aine  in  SOhltion,  and  in  the  medicinal  effects. 

As  these  cheap  and  inefficient  substitutes  are  frequently  dispensed  in- 
i»tead  of  the  genuine  preparation,  physicians  are  earnestly  requested, 
when  prescribing  the  Syrup,  to  write  *'Syr.  Hypophos.  Fellows." 

As  a  further  precaution,  it  is  advisable  that  the  Syrup  should  be 
irdered  in  the  original  bottles ;  the  distinguishing  marks  which  the  bot- 
;les  (and  the  wrappers  surrounding  them)  bear,  can  then  be  examined, 
uid  tiie  genuineness'— or  otherwise — of  the  contents  thereby  proved. 


HnioAx.  Lwrrsam  mat  bk  addrbsskd  to 


48  Vcsey  Street,  New  York, 


''The  Best  of  Prophets 
of  the  Future  is 

the     PaSt/^-Byron. 

There  is  no  speculation  or  theory  aoout 


The  test  of  time  has  proven  its  superlative  worth 
as  a  digestive  agent.  For  twenty  (20)  years  it  has 
been  steadily  prescribed  with  satisfaction. 

THE  PAST  IS  THE  PROPHET 
WHICH  PROVES  ITS  FUTURE. 

It  surpasses  pepsin  alone.  It  surpasses  pancreatin 
alone.  No  other  combination  has  ever  successfully 
imitated  LACTOPEPTINE. 


-^TIME  TRIES  ALL  THINGS, 
HOLD  FAST  TO  THAT 
WHICH  IS  GOOD.'' 

WCrW  FOn   SAMPLES   AND   LITERATURF.. 


jiw.yoRK  5' 


VJ^3 


IITTHERIV  PINE8,  ]V.  €.,  is  the  Best  Heath  Resort  in  the 
South.    Write  to  J.  T.  PATRICK    for  Information. 


tntj-Vtrnt  T««r. 


MARCH  20,  1898.  ▼•»•  *J 

NORTH  CAROLINA 

MEDICAL  JOURNAL. 

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If  you  have  any  doubt  whatever  concerning  the  value 
of  Taka-Diastase  as  a  starch  digestant,  we  ask  that  you 
apply  the  following  simple  test: 

Make  a  stiff  jelly  by  boiling  i  drachm  of  potato  starch 
in  3  ounces  of  water,  cool  to  body  temperature,  add  about  i 
grain  of  Taka-Diastase,  and  stir.  The  stiff  jelly  will  be  almost 
instantly  converted  into  a  watery  solution,  and  in  about  1 5 
minutes  all  the  starch  will  be  converted  into  sugars. 

Respectfully, 


^^r^aOt 


o/ir^o^ 


Home  OKIees  and  Laboratories,  Detroit.  Mich. 

Branches  In  New  York,  Kansas  City,  Baltimore,  and  New  Orleans. 


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PYROCTIN  has  the  endorsement  of  the  Medical  Professioi 

»s  in  the  administration  it  exercises  no  depressing  effect  upon  th( 

cardiac   muscle    but  on  the  contrary  is  an  systemic  exhilarant 

Samples  cheerfully^furnished  to  the  profession 

PRICEJTSc  per  ounce. 

The  Pyroctin  Company, 


FEVER 

Rheumati!  ^ 
for  Gout  &c. 

Intense  Pain  Wliere 
Norpiiine  is  Prohibited 

Malarial  fever 
Neuralgia,  Migraine  8c 


THE  MURRAY 

AgenU, 


DRUG   CO.,  Colnmbia,  8.  €.,  Distributi 


I 


ORTHOPEDIC 

Instruments. 


Trusses, 

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1030  UrALNVT  STREET,  PHILADELPHIA. 
CtMAlogoe  tent  on  Appltoatfeu. 


NORTH  CAROLINA 

MEDICAL  JOURNAL. 

A  SEMI-MONTHLY  JOURNAL  OF  MEDICINE  AND 
SURGERY. 

Vol.  XLI.  Winston,  March  20,    1898.  No.  6. 

g  - 

©riainal  (Tominunicatlons* 

ACUTE  GONORRHEA—WITH  ESPECIAL  REFERENCE 
TO  ITS  TREATMENT.* 

Stenographically  reported  and  accepted,  -with  remarks,  for  this 
•Journal  by  C.  C.  Mapes,  Louisville,  Ky. 


IT  was  thought  when  the  gonococcus  of  Neisser  was  isolated 
and  demonstrated  (?)  to  be  the  principal  etiological  factor, 
or  the  actual  causative  agent,  of  gonorrhea,  that  the  treat- 
ment of  this  disease,  which  had  hitherto  been  mainly  empirical, 
would  be  promptly  placed  upon  a  strictly  scientific  basis;  but 
years  have  come  and  g^ne,  and  while  many  new  methods  have 
been  suggested  as  to  management  and  treatment,  the  results 
seem  not  to  have  been  materially  influenced,  either  as  to  the 
duration  or  severity  of  the  disease;  nor  have  its  sequelae  been 
markedly  altered  or  diminished. 

It  is  recognized  if  the  nature  of  a  disease  is  not  accurately 
understood,  the  application  of  rational,  scientific  t'-eatment  is 
obviously  impossible;  moreover,  scientific  therapeutics  can  only 
displace  empirical  measures  when  fortified  by  a  thorough 
knowledge  of  physiological,  etiological  and  pathological  cer- 
tainties, as  well  as  precision  in  diagnoses. 

In  the  diagnosis   of  acute   gonorrhea  in    the   male   (and   this 

paper  deals  only  with  the  disease  in  the  sterner  sex)  there  should 

^Including  synopsis  of  a  paper    read  before  the  Louisville  Medico- 
Chirurgical  Society  by  John  L.  Howard,  M.D. 


,..  ACUTE  GONORRHCEA. 

1/4 

be  little  difficulty.  The  primary  manifestation  is  essentially  an 
inflammation  of  the  mucous  membrane  of  the  urethra,  marked 
by  a  mucopurulent  discharge  from  the  meatus  urinarius,  at- 
tended with  pain,  ardor  urinae,  etc.  The  discharge  is  not,  as 
the  name  gonorrhea  would  imply,  a  flow  of  semen,  but  is  of  a 
characteristic  mucopurulent  nature. 

Whether  the  specific  (so-called)  germ,  the  Durismopxdia  gonor- 
r/ia'ce,  the  gonococcus  of  Neisser,  plays  an  important  role  in  the 
propagation  of  the  disease,  will  not  be  discussed,  as  the  prin- 
cipal object  is  to  refer  to  the  treatment  of  gonorrhea  in  the 
acute  stage.  It  may  be  well  to  state,  however,  that  there  is  a 
marked  diversity  of  opinion,  among  those  upon  whom  we  must 
rely  as  authority,  in  regard  to  the  causative  agent,  and  it  is  the 
judgment  of  the  writer  that  the  matter  is  still  sub  judice.  The- 
oretically it  seems  to  have  been  finally  disposed  of,  but  practi- 
cally it  remains  unsettled.  It  is  true  gonococci  are  found  in 
the  discharge  of  gonorrhea,  but  it  is  likewise  certain  that  they 
have  been  discovered  in  the  secretions  of  the  healthy,  normal 
urethra,  so  their  presence  or  absence  cannot  be  said  to  have  any 
especial  clinical  significance. 

In  the  treatment  of  the  disease  under  consideration  is  also 
found  a  decided  difference  of  opinion,  and  this  applies  to  both 
general  and  local  medication.  As  an  instance,  one  writer  states 
that  the  disease  can  best  be  eradicated  by  persistent  retro- in- 
jections, while  another  claims  that  this  method  is  contraindi- 
cated,  and  so  on  ad  libitum. 

Following  is  a  resume  of  the  cases  covered  by  Dr.  Howard's 

paper  and  the  treatment  followed.      All  the  patients  were  treated 

at  French  Lick  Springs,  Indiana,  and  the  water  employed  came 

from  those  springs. 

******  * 

Case  1. — Male,  aged  34  years,  married,  contracted  first  attack  of 
gonorrhea  ten  days  previously.  Local  treatment  employed  during  this 
time  by  a  "specialist."  Discharge  abundant,  merismopoedia  gonor- 
rhoece  present  in  considerable  numbers;  whole  anterior  urethra  in- 
volved; considerable  irritation  at  the  cut-off  muscle,  owing  to  over- 
zealous  use  of  injections.  Local  treatment  discontinued  for  three  days, 
and  the  patient  directed  to  drink  four  glasses  of  water  ( about  three 
pints),  before  breakfast,  from  a  spring  having  an  aperient  as  well  as 
diuretic  action.  The  remainder  of  the  day  he  drank  trom  a  spring 
having  a   diuretic   action   only — six   glasses    between   breakfast   and 


ACUTE  tiONORRHCEA.  j  -  - 

dinner  and  suppei-,  two  at  bedtime.  For  two  or  two-and-a-half  hours 
after  each  meal  no  water  was  taken,  to  allow  for  stomach  digestion. 
Diet— all  acids,  uncooked  vegetables  and  fruits,  pastries,  tea  and 
coffee,  were  prohibited. 

At  end  of  the  third  day  average  specific  gravity  of  the  urine  was 
.1004  to  .1006;  quantity  passed  not  obtainable  because  of  frequent  uri- 
nations. Reaction  neutral  or  slightly  alkaline.  At  this  time  the  dis- 
charge had  changed  from  a  thick,  creamy  consistense  to  thin  and 
watery  in  character,  and  diminished  considerably  in  quantity.  He 
vv^ould  average  three  copious  stools  daily.  Thi'ee  times  daily  for  five 
days,  beginning  the  third  day,  the  anterior  urethra  was  flushed  thor- 
oughly from  the  meatus  with  hot  permanganate  of  potassium  solution, 
and  the  tz'eatment  stopped  after  two  bladder  v/ashiugs,  twenty-four 
hours  apart,  according  to  White's  method. 

Six  days  after  the  beginning  of  treatment  all  discharge  had  disap- 
peared. He  went  home  after  two  weeks  stay  at  the  springs,  and  has 
had  no  relapse. 

Case  2. — Male,  aged  27  years,  married,  first  noticed  urethral  dis- 
charge four  days  before  presenting  himself.  Had  not  consulted  a  phy- 
sician, but  had  izsed  injection  Brou  immediately  upon  detecting  the 
discharge.  Had  gonorrhea  three  years  previously.  The  same  course 
followed  in  case  1,  as  to  water  and  diet,  prescribed.  Hot  permangan- 
ate of  potassium  flushing  was  commenced  immediately.  At  the  end  of 
six  days  he  was  called  home,  and,  though  no  discharge  was  visible 
after  the, fifth  day,  the  following  was  prescribed: 

R — Bismuth  subgallate 1  dram. 

Zinci  sulphatis 18  grains. 

Aquse  calcis 6  ounces. 

M.  Sig.  to  be  used  as  an  injection  thrice  daily  after  urination.  He 
returned  to  the  springs  four  weeks  later  having  had  no  recuri'ence  of 
the  disease. 

Case  3. — Drummer,  20  of  age,  married,  presented  a  swollen  organ; 
glands  in  both  groins  enlarged  and  tender;  lips  of  meatus  congested 
and  almost  denuded  of  epithelium;  an  abundant  mucopurulent  dis- 
charge streaked  with  blood;  both  deep  and  anterior  urethra  involved; 
prostate  congested;  cord  and  testicles  tender.  The  discharge  appeared 
three  days  before.  He  had  procured  some  tablets  containing  about 
two  grains  each  of  sulphate  of  zinc,  and  making  a  solution  of  six  to 
the  ounce,  had  lost  no  time  and  neglected  no  occasion  to  inject  it 
"deep  and  strong"  with  a  long-tipped  penis  syringe.  Knowing  it  to 
be  useless  no  test  was  made  for  the  specific  germ.  Because  of  acute- 
ness  of  the  attack,  and  slight  urethral  fever,  he  was  kept  in  bed  forty- 
eight  hours,  given  a  thorough  saline  catharsis,  and  allowed  all  the 
diuretic  water  he  could  drink. 

The  third  day  he  took  slight  exercise,  the  testicles  being  supported 
by  a  suspensory  bandage;  by  the  fifth  day  the  discharge  had  lost  most 


j-g  ACUTE  GONOKriHCEA. 

of  its  purulent  chai-acter;  no  blood  was  noticed  after  the  second  day. 
He  wtts  then  given  daily  a  thorough  washing,  by  White's  method,  for 
five  successive  days,  and  left  for  home  on  the  twelfth  day.  There  has 
been  no  return  of  the  trouble. 

Twenty  or  thirty  cases  of  gonorrhea  were  treated  by  this 
plan  and  uniformly  good  results  were  obtained.  The  average 
duration  of  the  disease  was  less  than  three  weeks,  and  no  case 
was  under  actual  observation  over  two  v.-ecks. 

Under  ordinary  circumstances  in  treating  gonorrhea,  the 
patient  being  allowed  to  attend  to  business  and  do  his  own  in- 
jecting, the  duration  is  from  four  to  six  weeks,  and  often  to  the 
annoyance  of  the  physician  and  disgust  of  the  patient  chronic 
urethritis  supervenes,  with  various  complications,  which  may 
last  for  months. 

That  gonorrhea  is  one  of  the  most  unsatisfactory  diseases  to 
tre£t  is  no  fault  of  the  physician.  As  a  rule  the  patients  are 
drinkers,  and  in  cities  it  is  sometimes  impossible  to  control  this 
feature.  The  cares  of  business  and  exciting  diversions  of  city 
life  are  opposed  to  regular  habits  and  proper  medication.  We 
cannot  send  patients  to  mineral  springs,  but  we  can  insist  upon 
regular  habits,  proper  diet,  etc.,  and  facilitate  treatment  by 
daily  visits  of  the  patient  to  the  physician's  office. 

In  drawing  deductions  from  the  cases  reported,  v/e  must  con- 
sider that  the  majority  of  the  patients  were  married  men, 
especially  desirous  of  speedy  cure,  whose  habits  and  diet  were 
easily  regulated ;  that  all  alcoholic  drinks  were  avoide-;  that 
they  were  not  allowed  to  do  their  own  injecting;  that  they  had 
access  to  natural  spring  Vv-aters  which  produced  the  best  possi- 
ble diuretic  and  cathartic  effects,  increasing  cell  metabolism, 
especially  of  the  glandular  organs,  and  alkalizing  the  blood, 
thereby  putting  the  patients  in  excellent  physical  condition. 

The  local  treatment  of  gonorrhea  is  but  a  secondary  consid- 
eration, nevertheless  it  is  of  the  utmost  importance.  Improper 
injections  used  by  ignorant  hands  is  the  chief  cause  of  pro- 
longed and  complicated  cases.  Two  cases  of  gonorrhea  at 
French  Lick  Springs  recovered  without  any  local  treatment,  by 
simply  observing  rules  as  to  diet,  and  habits,  and  drinking 
copiously  from  the  "Bowles  Spring,"  the  water  of  which  has  a 
powerful  diuretic  action. 

We  are  prone  to  become  too  mechanical  in  the  local  treatment 


ACUTE  GONORRIICEA.  j-- 

of  gonorrhea;  we  should  never,  in  acute  urethritis,  insert  an  in- 
strument with  the  view  of  giving  a  so-called  retro-injection,  or 
making  local  application.  The  too  early  passage  of  a  sound 
will  ignite  the  smouldering  spark  and  renew  trouble  which 
would  ?oon  have  disappeared  without  this  irritation. 

The  remedial  agents  giving  the  best  results  are  permanga- 
nate of  potassium  and  sulphate  of  zinc.  Permanganate  of  pot- 
assium, as  an  antiseptic,  should  be  used  only  in  a  hot  solution, 
the  amount  of  heat  being  the  highest  degree  which  can  be  tol- 
erated by  the  patient.  The  gonococcus  is  killed  at  120°  F., 
and  its  spores  die  at  [40°  F.,  A  moist  temperature  of  ioS°  to 
110°  F.  renders  the  germs  almost  inactive,  and  if  exposed  re- 
peatedly to  this  temperature  they  sicken  and  die.  Therefore 
when  it  is  possible  to  begin  hot  permanganate  flushing  early 
we  will  ultimately  have  fewer  spores  with  which  to  deal,  as  the 
sporogenous  germs  cannot  thrive  if  such  injections  are  properly 
employed. 

It  is  seldom  necessary  to  use  over  fifteen  grains  of  permanga- 
nate of  potassium  to  the  pint,  and  careful  observation  should 
guard  against  irritating  with  a  too  strong  solution. 

Sulphate  of  zinc  undoubtly  stands  at  the  head  of  astringents 
for  urethral  injections;  six  or  eight  graing  to  the  ounce  may  be 
used  in  some  cases  without  detriment,  though  two  or  three  gra- 
ins are  usually  sfficient. 

As  a  final  injection,  when  nothing  but  a  slight  muco-serous 
discharge,  or  "  tear  "  is  visible,  the  subgallate  of  bismuth  com- 
bined with  zinc  sulphate  proves  satisfactory,  according  to  the 
formula  already  mentioned. 

The  natural  spring  waters  and  inorganic  salts  should  rank 
first  as  diuretics  and  blood  alkalizcrs  in  the  treatment  of  gono- 
rrhea. These  waters  are  easily  obtained  and  in  addition  to  any 
special  action,  by  their  use  the  patient's  general  condition  is 
improved.  Balsams  and  proprietary  vegetable  compounds  may 
temporarily  sterilize  the  urine,  but  the  digestive  organs  are  tax- 
ed to  such  extent  that  the  beneficial  effects  are  counterbalanced. 
******* 

The  importance  of  patients  suffering  acute  gonorrhea  ingest- 
ing large  quantities  of  water,  for  its  effect  in  flushing  and  clean- 
sing the  bladder  and  urethra,  has  long  been   recognized;  indeed 


J -8  ACUTE  GONORRHCEA. 

we  doubt   not  it   was  regarded   as  appropriate  for  relief  of  the 
"  running  issue  of  the  flesh  '   mentioned  in  Scriptural  literature. 

The  statement  that  gonorrhea  has  been  cured  in  a  compara- 
tively short  space  of  time  by  the  free  ingestion  of  natural  spring 
waters,  no  matter  what  iheir  composition  is,  without  other 
treatment  ar  attention,  either  local  or  general,  save  a  careful  ob- 
servation of  certain  rules  and  regulations  as  to  diet  and  habits, 
comes  to  us  in  the  nature  of  a  surprise,  since,  according  to  the 
admission  of  some  of  the  best  authorities  in  the  world,  by  the 
most  careful  and  diligent  local  and  general  treatment  it  is  un- 
safe for  a  physician  to  promise  an  absolute  cure  under  ten  to  six- 
teen weeks,  and  even  then  that  complications  may  occur  which 
will  lengthen  the  duration  of  the  disease  to  many  months. 

Not  long  ago  Van  Buren  declared  that  more  people  die  of 
gonorrhea  than  of  syphilis,  and  Noeggerath  followed  with  the 
statement  that  a  man  never  recovers  from  a  severe  attack  of 
gonorrhea;  that  nine-tenths  of  the  women  who  marry  men  who 
have  had  gonorrhea  become  the  subjects  of  painful  and  incur- 
able inflammatory  diseases  of  the  uterus,  tubes  or  ovaries,  a  de- 
claration the  truthfulness  of  which  has  been  often  confirmed  and 
certainly  too  well  understood  to  require  further  comment. 

The  researches  of  modern  bacteriologists  suggests  that  the  se- 
quelae of  gonorrhea  are  numerous  and  alarmingly  severe,  that 
the  disease  cannot  be  pronounced  cured  upon  cessation  of  the 
urethral  discharge,  that  the  fons  et  origo  may  lurk  in  the  rugae 
of  the  deep  urethra  for  an  indefinite  period,  and  slight  stimula- 
tion may  excite  renewed  invasion. 

The  question,  when  can  a  man  be  pronounced  cured  of  a  viru- 
lent gonorrhea,  if  treatment  is  instituted  during  the  acute  stage, 
is  extremely  pertinent,  and  one  which  merits  recognition  from 
everyone  having  at  interest  the  welfare  of  human  posterity. 

When  shall  the  gonorrheic  be  allowed  to  marry,  is  also  a  matter 
of  equal  importance.  That  occasionally  a  man  already  married 
should  contract  gonorrhea,  or  subject  himself  to  infection,  is  a 
calamity,  which,  in  rerum  natura.  it  seems  almost  impossible  to 
avert,  and  transmission  of  the  loathsome  disorder  to  his  con- 
nubial partner  is  almost  certain  to  take  place;  regardless  of  the 
fact  that  he  be  enjoined,  urged,  commanded,  by  his  physician 
to  abstain   from  sexual  indulgence  for  a  certain  period,  as  soon 


GOELET.-SHORTENING  OF  THE  ROUND  LIGAMENTS.  j-q 

as  the  discharge  ceases  from  the  meatus  urinarius,  sometimes 
even  before,  his  sexul  relations  are  resumed  with  the  result  of 
infiicting  degradation  and  sufferijig  upon  his  innocent  wife  and 
perhaps  his  unborn  child,  as  evidence  on  the  one  hand  by  rad- 
ical operations  for  gonorrheal  phyosalpinx,  etc.,  and  blindness 
from  ophthalmia  neonatorum  on  the  other. 

This  is  a  gloomy  picture  to  contemplate,  but  it  is  neverthe- 
less true,  and  might  better  be  faced  and  discussed  intelligently 
and  plainly  by  all  concerned  than  be  relegated  to  the  back- 
ground, when  by  the  latter  procedure  innocent  persons  may  be 
infected  with  a  malady,  insidious  and  dangerous  in  its  signif- 
icance,   which  might  have  been  prevented. 

Prevention  of  the  spread  of  venereal  disease  is  an  important 
question — sanitary,  hygienic,  sociologic,  legal,  physical,  mental 
moral,  etc.  etc. — and  it  may  be  stated  that  the  only  manner  in 
which  it  can  be  accomplished  is  by  avoiding  contact  with  its 
infectious  or  contagioug  influences;  and  its  limitation  or  control, 
when  once  disseminated,  is  a  matter  which  concerns  the  mor- 
alist, the  philanthropist,  the  wise  statesman,  and  the  eminent 
medical  man. 


Clinical  Xccturc6. 

DEMONSTRATIONS    IN    OPERATIVE     GYNECOLOGY 
AT    THE   MANHATTAN  SANATORIUM. 

By  Augustin  H.    Goelet,   M.D.,   Professor  of  Gynecology  in 
the  New  York  School  of  Clinical  Medicine,  etc. 


SHORTENING  OF  THE  ROUND  LIGAMENTS  BY  A  NEW  METHOD,  FOR 
REDUCIBLE  RETROFLEXION  OF  THE  UTERUS. 


THE  operation  which  I  will  show  you  to-day  is  for  retroflex- 
ion  of  the   uterus.      The   organ   is   freely   movable    and 
readily  replaced,  but  it  will  not  retain  its  proper  position 
without  the  support  of  a  pessary,  which  is  a  source  of  discom- 


I  So  GOELET— SHORTENING   OF   THE  ROUND  LIGASIENT. 

fort.  The  displacement  is  of  long  standing,  and  there  is  a 
chronic  metritis  and  endometritis  which  increases  the  weight 
and  size  of  the  organ.  It  is  therefore  difficult  to  adjust  any 
form  of  artificial  support  in  the  vagina  in  these  cases  to  main- 
tain the  uterus  in  position  without  producing  more  or  less  dis- 
comfort. You  are  well  aware  that  the  pessary  never  effects  a 
cure  in  such  cases,  and  that  unless  some  form  of  operation  is 
done  the  patient  is  doomed  to  wear  it  forever.  The  main  uterine 
supp:)!-t5  have  lost  completely  their  tone  and  sustaining  power. 
It  is  very  important  however  that  preparatory  for  this  operation 
which  we  are  to  do  here,  the  displacement  should  be  overcome 
and  a  pessary  adjusted  which  will  maintain  the  uterus  in  a  cor- 
rect position,  since  this  additional  support  is  needed  for  a  short 
time  afterwards,  that  too  much  strain  may  not  at  first  be  put 
upon  the  round  ligaments.  Besides  the  preparatory  treatment 
it  is  also  important  to  overcome  the  metritis  and  endometritis 
so  that  the  oagan  may  be  reduced  in  size  and  weight. 

We  therefore  curette  the  uterus  first  and  pack  it  with  iodo- 
form gauze.  This  gauze  is  always  removed  at  the  end  of  forty- 
eight  hours  and  usually  it  is  not  renewed:  The  pessary  which 
was  removed  is  now  replaced. 

The  operation  which  I  will  do  to  sustain  the  uterus  is  shorten- 
ing the  round  ligaments,  but  instead  of  adopting  the  usaul  tech- 
nique and  opening  the  inguinal  canal  at  the  external  ring  which, 
for  many  reasons,  is  objectionable  I  shall  enter  the  canal  through 
a  very  small  incision  over  the  internal  ring  as  suggested  by 
Kellog. 

The  advantages  of  this  operation  over  the  other  method  of 
shortening  the  round  ligaments  are,  viz. 

1.  The  ligaments  are  not  cut  or  detached. 

2.  The  inguinal  canal  is  not  laid  open  and  it  leaves  no  liability 
to  hernia. 

3.  The  iigament  at  this  point  (the  internal  ring)  can  always 
be  found  and  is  strong  enough  to  bear  shortening  and  suitain 
the  uterus. 

4.  The  operation  can  be  more  quickly  executed,  requiring 
not  more  than  ten  minutes  for  each  side,  from  start  to  finish. 

5.  The  ligament  is  buried  in  succulent  muscle  which  provides 
ample  nutrition. 


GOELET.- SHORTENING  OF  THE  ROUND   LIGAMENTS.  jgj 

6.  The  attachment  is  secure  and  does  not  give  vv^ay. 

7.  Primary  union  always  takes  place. 

8.  It  does  not  require  more  than  an  inch  incision  in  the  skin 
and  not  more  than  a  quarter  of  an  inch  ir  cision  into  the  canal, 
and  no  disfiguring  scar  remains. 

The  pubis  has  been  shaved  and  the  surface  of  the  abdomen 
has  been  rendered  aseptic.  Selecting  now  a  point  midway  be- 
tween the  anterior  superior  spine  of  the  ileum  and  the  symphy- 
sis pubis  we  locate  the  internal  ring.  Here  we  make  an  incis- 
ion an  inch  in  length,  parallel  to  Poupart's  ligament,  through 
the  skin  and  underlying  fascia  down  to  and  exposing  the  exter- 
nal oblique  muscle.  Two  retractors  are  inserted  and  the  lower 
edge  of  the  incision  is  retracted  downward  until  it  exposes 
Poupart's  ligament.  With  a  very  small,  narrow  bladed  knife, 
an  incision  is  made  through  the  muscles  just  above  the  ligament, 
no  longer  than  the  bredth  of  the  knife  blade,  extending  down 
into  the  inguinal  canal.  By  means  of  a  blunt  hook  inserted 
through  this  incision  into  the  canal  the  ligament  is  caught  and 
drawn  out.  You  see  the  ligament  is  quite  thick  at  this  point, 
and  is  readily  drawn  out.  Stripping  the  ligament  it  will  move 
more  freely  and  we  thus  separate  from  it  the  accompanying 
nerve.  We  must  be  careful  to  avoid  handling  or  bruising  the 
ligament,  as  it  often  sloughs  if  roughly  handled.  We  draw  it 
out  as  much  as  possible  so  as  to  be  sure  that  the  fundus  of  the 
uterus  is  brought  well  forward. 

Now  as  to  the  method  of  attaching  the  ligament  and  closing 
the  wound.  This  is  very  simple  and  is  accomplished  with  two 
deep  sutures  of  silkworm  gut  Vv'hich  close  the  wound  and  secure 
the  ligament  at  the  same  time.  The  first  of  these  sutures  is  in- 
serted near  the  upper  angle  of  the  incision  through  the  skin, 
first  above  it  and  a  quarter  of  an  inch  from  the  margin  using  a 
medium  quarter  curved  needle.  Then  it  is  carried  through  the 
muscular  margins  of  the  incision  opening  into  the  canal  pene- 
trating the  upper  part  of  the  loop  of  the  round  ligament  as  it 
comes  through  this  incision.  The  suture  then  emerges  through 
the  skin  on  the  lower  side  of  the  wound  at  a  point  opposite  its 
insertion.  The  free  ends  of  this  suture  are  grasped  with  a  pair 
of  pressure  forceps.  The  fibres  of  the  external  oblique  muscle 
above   the   small   incision    opening  into   the   canal  an   inch   in 


igj  ROBERTS.-SUBCUTONEOrS  TENOTOMY,  ETC. 

breadth  is  seized  and  penetrated  with  a  threaded  aneurism  needle 
The  opening  made  by  the  needle  being  enlarged  by  a  lateral 
motion,  the  loop  of  round  ligament  is  caught  in  th<i  ligature 
loop  of  the  needle  and  drawn  through  under  the  fibres  of  the 
muscle  as  the  aneurism  needle  is  withdrawn.  This  loop  of  the 
round  ligament  is  now  folded  down  across  Poupart's  ligament. 
The  second  suture  is  now  inserted  near  the  lower  angle  of  the 
incision  in  the  skin,  catches  the  free  loop  of  the  round  ligament 
as  it  emerges  from  under  the  external  oblique  above,  then 
catches  the  muscle  at  the  lower  border  of  the  incision  opening 
into  the  canal  next  the  extremity  of  the  loop  of  the  round  lig- 
ament and  emerges  on  the  skin  surface  below,  at  a  point  oppo- 
site its  insertion.  These  sutures  being  tied,  as  you  see,  close  the 
wound  and  secure  the  looped  round  ligament  firmly  buried  in 
the  belly  of  the  external  oblique  muscle. 

The  same  thing  is  now  repeated  on  the  other  side. 

The  wounds  are  dressed  in  the  same  manner  as  the  coeliotomy 
wound,  being  covered  with  dry  markasol,  and  over  this  is  placed 
a  pad  of  plain  gauze  held  in  place  by  adhesive  strips  and  a 
bandage. 

The  sutures  will  be  left  undisturbed  for  two  weeks  and  the 
patient  will  be  kept  quiet  in  bed,  when,  if  union  is  perfect,  they 
are  removed  and  after  two  days  the  patient  is  permitted  to  get 
up.  The  pessary  is  worn  for  a  month  after,  when  it  may  be 
removed. 


Selcctcb  lpapcr0. 


SUBCUTANEOUS  TENOTOMY  AS  AN  AID  IN  THE 
REDUCTION  OF  FRACTURES. 

By  John  B.  Roberts,   M.D.,  Philadelphia. 


THE  treatment  of  fractures  has  received  much  consideration 
in  recent  years  and  many  suggestions  of  value  have  been 
mentioned.      Some  practitioners,   however,   seem   to  re- 
gard fractures  as  injuries  belonging  to  a  department  of  surgery 
in  which  no  advances  have  been    made,  and    they  continue   the 


ROBERTS.-SUBCUTANEOUS  TENOTOMY,  ETC.  j8? 

routine  measures  of  the  last  generation.  It  is  this  conservatism 
or  want  of  progress  in  surgical  practice  that  leads  me  to  call 
attention  to  tenotomy  as  an  aid  in  the  reduction  of  fractures 
and  displacement.  The  suggestion  was  made  a  good  many- 
years  ago  by  someone;  and  it  has  been  used  by  many  surgeons 
with  great  satisfaction.  It  is  not,  I  think,  employed  as  often 
as  it  should  be,  because  its  simplicity  and  effectiveness  have  re- 
ceived such  scant  recognition.  Its  adoption  by  every  physician 
who  knows  how  to  perform  an  aseptic  subcutaneous  division  of 
a  tendon,  would,  I  am  convinced,  result  in  lessening  the  num- 
ber of  cases  of  deformity  after  fractures,  especially  of  the  tibia 
and  fibula.  Surgical  specialists  are  well  aware  of  its  useful- 
ness in  oblique  fractures  of  the  leg  near  the  ankle,  but  I  am  not 
sure  that  even  they  adopt  it  as  often  as  is  desirable  in  fractures 
of  the  shaft  of  the  tibia  and  fibula.  One  who  has  cut  the 
tendon  of  Achilles  in  tibial  fractures  in  which  the  ordinary 
fracture-dressings  seemed  unavailing  in  preventing  overriding 
and  deformity  will  be  pretty  sure  to  adopt  it  in  subsequent 
cases.  The  ease  with  which  reduction  is  effected  and  coapta- 
tion maintained  is  a  source  of  much  satisfaction,  after  such  an 
operation. 

It  is  essential  that  the  skin  and  the  tenotome  be  madeaseptic 
and  that  the  whole  tendon  be  cut.  If  a  few  fibers  are  left  un- 
divided, the  heel  will  still  be  drawn  up  by  the  calf-muscles  and 
the  operation  will  fail  of  its  object.  If  the  operator  can  feel 
through  the  skin  a  distinct  gap  between  the  cut  ends  of  the 
tendon,  showing  that  the  whole  width  and  thickness  of  the 
tendon  have  been  severed,  the  fragments  will  be  rasily  adjusted  ; 
and  will  be  kept  in  proper  position  by  any  simple  form  of  reten- 
tive fracture-dressing  he  may  prefer.  The  pain  due  to  spas- 
modic contractions  of  the  calt-muscles  will  be  absent  after  such 
a  tenotomy  and  the  patient's  comfort  thereby  greatly  increased. 
The  puncture  made  by  the  tenotome  is  to  be  covered  by  a 
compress  of  aseptic  gauze  or  sealed  with  a  little  aseptic  cotton 
or  gauze  held  in  place  with  collodion. 

This  little  operation,  to  which  I  have  been  resorting  for  years 
in  selected  cases,  does  not  appear  to  impair  the  subsequent 
power  and  usefulness  of  the  foot.  It  obviates  the  necessity  for 
complicated  fracture-appliances  to  overcome  spasm  of  the  calf- 


|;84  MORRILL.-FOR  WHAT  PERIOD  OF  TIME  CAN  IMMUNITY,  ETC 

muscles,  which  are  causing  pain  and  displacement  of  the  ends 
of  the  broken  bone. 

I  have,  so  far  as  I  recollect,  only  employed  tenotomy  in  this 
manner  for  aiding  the  reduction  of  fractures  of  the  leg.  It 
would  probably  be  available  in  fractures  of  the  upper  part  of 
the  femoral  shaft,  when  the  ilio-psoas  muscle  flexes  and  everts 
the  upper  fragment.  The  operation  here  would  probably  re- 
quire open  incision  and  inspection  of  the  parts,  in  order  to  divide 
the  tendon  without  injuring  important  structures  in  its  neigh- 
borhood. It  would  perhaps  take  the  place  of  cutting  down 
upon  and  wiring  the  fragments  in  these  troublesome  fractures. 

The  tilting  up  of  the  inner  fragment  in  some  fractures  of 
the  clavicle  could  probably  be  avoided  by  subcutaneous  tenot- 
omy of  the  clavicular  portion  of  the  sterno-cleido-mastoid  mus- 
cle. The  upward  displacem,ent  of  the  olecranon  after  fracture 
might  be  managed  in  the  same  way,  if  it  were  difficult  to  ob- 
tain and  maintain  coaptation. 

There  is  a  possibility  that  intra-articular  operations  for  bring- 
ing together  the  fragments  in  transverse  fracture  of  the  patella 
may  be  avoided  by  a  free  tenotomy  and  myotom.y  of  the  four- 
headed  extensor  muscle  of  the  thigh. — Phil.  Med.  Jour. 


FOR  WHAT  PERIOD  OF  TIME  CAN  IMMUNITY  FROM 
DIPHTHERIA    BE  CONFERRED  BY  A  SINGLE  IN- 
JECTION OF  ANTITOXIN?     THE  DOSAGE. 

By   F.    Gordon   Morrill,     M.  D.,    Visiting  Physician    to    the 
Children's  Hospital  Boston. 


WHILE   one  reads  an  occasional  mention  of  immunization 
against  diphtheria  in  the  journals, the  literature  of  the  sub- 
ject is  vague  and  unsatisfactory  as  regards  the  vit  \1  ques- 
tion.   For  how  long  a  time  can  safety  be  insured,  and  what  is  the 
proper  dose  of   antitoxin?     The  most  satisfactory  report  which  I 
have  seen  is  that  of  Dr. Hermann  Mr.  Biggs,of  New  York, "The 


MORRILL.— FOR  WifAT  PERIOD  Oj^  TI?,IE  CAN  IMMUNITV,   KTC.  jg- 

Use  of  Antitoxin  Serum  for  tine  Prevention  of  Diphtheria,  "  to 
which  I  shall  have  occasion  to  refer  later  on.  The  longest  paper, 
or  rather  series  of  papers  of  which  I  have  any  knowledge  is  that 
of  Kassowitz,*  slightest  degree  of  immunity.  To  arr-ve  at  any- 
thine  like  a  definite  and  respectable  conclusion  as  to  what  can 
or  cannot  be  achieved  in  the  prevention  of  diphtheria  the  care- 
ful personal  observation  of  a  large  number  of  recorded  cases  dur- 
ing a  period  of  yeari;  is  required,  and  it  has  been  cur  good  (or  bad) 
fortune  to  have  used  antitoxin  for  immunization  at  the  Children'^ 
Hospital  since  January  13,  1895  ;  and  while  my  object  in  prepa- 
ring this  paper  has  been  to  present  what  I  believe  to  be  the  truth 
about  immunization,  rather  than  to  answer  Dr.  Kassowitz,  I 
venture  to  hope  that  I  can  at  least  cast  a  substantial  doubt  upon 
the  soundness  of  his  conclusions  and  means  (in  part)  by  which 
he  has  reach  them. 

An  outline  sketch  of  what  has  been  done  to  prevent  the  oc- 
currence ot  diphtheria  in  our  wards,  and  of  the  circumstances 
which  led  to  our  adoption  of  a  system  which  we  still  employ  is 
as  follows: 

For  years  we  had  been  seriously  handicapped  by  occasional 
outbreaks  of  diphtheria  in  the  hospital,  and  during  the  year  of 
1894  we  were  obliged  to  discharge  every  child  in  the  house  and 
close  our  door  on  three  separate  occasions.  After  each  of  these 
endemics  we  went  through  a  thorough  process  of  cleaning  and  dis- 
infection, and  enforced  such  rules  as  to  the  admission  of  visitors 
as  seemed  likely  to  prevent  a  recurrence  of  the  trouble.  But 
notwithstanding  these  precautions,  on  January  13,  1895,  we 
were  confronted  by  the  serious  fact  that  we  had  three  clinical 
and  six  of  what  we  soon  learned  to  regard  as  bacteriological  cases 
of  diphtheria  in  our  infectious  ward;  and  the  question  of  closing 
the  hospital  for  the  fourth  time  within  twelve  months,  or  try- 
ing what  immunization  might  do  to  aid  us  in  keeping  our  doors 
open  and  going  on  with  our  work,  arose,  and  the  latter  course 
decided  upon.  Accordingly  all  the  children  and  nurses  were  in- 
jected, and  with  complete  success  so  far  as  promptly  stopping  the 
further  development  of  any  symptoms  which  were  thought  to 
characterize  diphtheria  previous  to  the  birth  of  the  Kleb-Loeffler 
bacillus. 

*  Vienna  Medical  Weekly,  May  IH,  189«. 


l36         MORRILL. -FOR  WHAT  PERIOD   OF  TIME  CAN  IMMUNITY,   ETC. 

At  that  time  there  prevailed  decidedly  vague  notions  as  to 
what  could  be  accomplished  in  the  way  of  immunization,  and 
the  amount  of  serum  injected  for  the  purpose  was  too  small, 
150  units  being  the  usual  dose  employed. 

Equally  indefinite  ideas  as  to  the  significance  of  the  presence 
of  the  bacillus /<?r  se  were  in  vogue,  and  we  fell  readily  into  line 
with  the  opinion  that  this  alone  constituted  diphtheria;  and 
thus  fresh  terrors  were  attached  to  a  name  which  we  had  al- 
ready sufficient  cause  for  disliking.  So  that  while  we  congrat- 
ulated ourselves  upon  having  escaped  a  very  immediate  danger, 
the  question  of  how  often  to  inject  remained  to  be  settled;  and 
while  sending  all  children  who  had  the  bacillus  but  no  clinical 
symptoms  of  diphtheria  to  the  infectious  ward  seemed  rather  a 
harsh  measure,  we  feared  the  disapproval  of  the  bacteriologists 
if  we  failed  to  perform  what  they  proclaimed  to  be  an  obvious 
duty,  all  of  which  resulted  in  an  overcrowding  of  the  infectious 
ward,  and  a  great  waste  of  serum,  which  we  used  in  frequently 
repeated  injections  in  such  cases  as  had  the  bacillus,  but  no  cli- 
nical symptoms,  hoping  thereby  to  rid  our  patients  of  microbes 
which  were  really  doing  them  no  harm. 

Each  child  was  injected  upon  entering  the  house,  and  cultures 
were  made  to  the  extent  that  we  were  able  to  impose  upon  the 
good  nature  of  the  gentlemen  at[the  Bacteriological  Laboratory  of 
the  Harvard  Medical  School  (who  certainly  did  all  in  their  power 
to  aid  us),  and  deluded  with  the  belief  that  each  new  discovery 
of  the  bacillus  meant  a  fresh  infection,  the  interval  permittted 
to  elapse  between  the  routine  immunizations  of  well  children 
was  fixed  at  thirteen  days;  so  that  while  the  doses  given  were 
too  small,  their  frequency  made  up  for  this  deficiency  in  a  great 
majority  of  cases  so  far  as  the  prevention  of  clinical  diphtheria 
was  concerned.  On  May  5th  the  infectious  ward  was  empty, 
all  throats  and  noses  were  free  of  the  bacillus,  and  our  cxperi- 
rience  could  be  briefly  sunamed  up  as  follows:  None  of  the 
children  who  had  been  sent  to  the  infectious  ward  with  merely 
bacillary  throats  or  noses  had  manifested  any  symptoms  of  clin- 
ical diphtheria,  although  thoroughly  exposed  to  infection  both 
from  their  own  mucous  membranes  and  from  patients  having 
well-marked  deposits  of  diphtheritic  membrane. 

Two  emergency  cases  had  broken   down   within    twenty-four 


MORRILL.-FOR  WHAT  PERIOD   OF  TIAIE   CAS  IMMUNITY,    ETC.         jg? 

hours  of  admission  and  immunization.  One  boy  who  had  re- 
ceived 150  units  January  29th  had  unmistakable  symptoms  Feb- 
ruary 15th  ;  and  a  girl  who  had  been  injected  with  a  like  amount 
broke  down  March  25th.  No  antitoxin  was  used  (excepting  for 
curative  purposes  in  cases  which  I  shall  shortly  mention)  after 
May  15th  until  the  succeeding  autumn. 

June  30th  two  girls  returned  from  the  Convalescent  Home  at 
Wellesley  with  diphtheria. 

July  14th  Theresa  R.,  and  August  5th  William  M.,  were  sent 
over  to  the  infectious  ward  from  the  house. 

On  November  15,  1895,  immunization  was  again  begun  and 
our  statistics  up  to  that  date  are:  Of  279  immunized  children, 
four  had  diphtheria — two  of  these  within  twenty-four  hours 
after  injection  and  two  from  the  fact  (as  I  shall  hope  to  prove) 
that  the  amount  of  antitoxin  used  was  altogether  too  small. 
As  to  the  first  two  cases,  it  is  merely  stating  a  tiuism  to  say  that 
one  can  immunize  too  late,  just  as  one  may  vaccinate  too  late, 
and  that  such  cases  are  merely  the  natural  results  of  (often  un- 
avoidable) delay. 

Of  414  non-immunized  patients  who  were  in  the  house  be- 
tween May  15th  and  November  15th,  four  had  diphtheria;  and 
this  at  a  time  when  the  disease  was  far  less  prevalent,  and  when 
open  windows  afforded  free  ventilation  for  those  in  the  hospital, 
while  the  two  who  broke  down  at  Wellesley  had  enjoyed  plenty 
of  outdoor  air. 

In  view  of  our  previous  experience,  it  was  now  decided  to  in- 
ject each  child  in  the  bath-room  on  admittance  before  permitting 
it  to  enter  any  of  the  wards — the  amount  to  be  injected  being 
fixed  at  one-half  the  curative  dose  for  children  of  eight  or  over, 
one-third  for  those  between  five  and  eight,  and  one-fourth  for 
patients  between  two  and  five.*  No  delay  was  permitted  (for 
bacteriological  examination)  in  the  admission  of  patients,  but 
all  new  cases  were  sent  into  rooms  in  the  last  wing,  there  to 
remain  until  their  cultures  showed  their  fitness  to  occupy  beds 
in  the  common  wards.      To  this  section  of  the  house  were   also 

*Fi'om  November  15.  I»y5,  to  March  16,  18%,  the  serum  made  by  Dr. 
Ernst  was  used;  and  the  test  of  potency  being  based  on  the  French 
system,  affords  no  satisfactory  means  of  comparison  with  the  present 
standard  in  units.  Since  the  last-mentioned  date  we  have  been  sup- 
plied by  the  State  Board  of  Health,  and  the  dosage  fixed  by  the  pre- 
vailing standard. 


1 83        MORPJLL.-FOR   V.'IIAT  PEr.IOD   OF   TIMi:   CAN   IMJirNITY,   ETC. 

sent  all  cases  acquiring  the  bacillus  while  in  the  hospital.  The 
injections  were  repeated  every  28  days,  and  in  case  of  fresh  dis- 
coveries of  the  microbe  the  children  having  it  were  at  once  in- 
jected providing  10  days  had  elapsed  since  their  last  in^.muniza- 
tion. 

December  15,  1895,  Dr.  H.  W.  Gross  entered  upon  his  duties 
as  bacteriologist  to  the  hospital,  and  weekly  cultures  were  made 
from  every  throat  and  nose  in  the  house. 

Duiin;.;  l!;c  winter  and  succeeding  spring  (1S96),  although 
nearly  eight  per  cent,  of  the  children  had  the  bacillus,  and 
we  were  free  from  its  presence  for  five  days  only,  as  shown  by 
the  cultures,  the  only  cases  of  diplitheria  were:  a  case  in  which 
the  antitoxin  was  accidentally  omitted  for  36  days,  and  two  who 
were  sent  to  the  City  Hospital  from  Wellesley  after  omission  of 
immunization  for  three  months  and  43  days  respectively.  By 
the  middle  of  May  all  the  cultures  were  negative  and  injections 
stopped. 

During  the  summer  no  cases  of  diphtheria  occurred  and  we 
did  not  resume  the  antito.xin  until  November,  1896,  when  we 
determined  to  pay  no  further  attention  to  the  bacillus,  but  to 
simply  inject  every  28  days  with  the  same  dose  employed  dur- 
ing the  preceding  winter.  The  result  of  the  previous  year  being: 
Of  421  children  injected  every  four  weeks,  none  had  diphtheria, 
while  of  425  either  non-immunized  patients  or  in  whom  the 
serum  had  been  omitted  fo/  at  least  36  days,  three  had  con- 
tracted the  disease. 

Accordingly,  no  further  cultures  were  made,  and  applicants 
were  freely  admitted  to  the  common  wards.  All  went  well 
until  February  18,  1896,  when  a  boy  of  ten  was  sent  to  the  City 
Hospital  from  Wellesley  23  days  after  receiving  250  units.  It 
was  not  thought  best,  however,  to  shorten  the  intervals  on  ac- 
count of  the  exception,  particularly  in  view  of  the  fact  that  an 
insufficient  amount  had  been  used,*  and  matters  proceeded  as 
before  until  March  5th,  when  a  girl,  age  six,  who  had  been 
given  300  units  23  days  previously  showed  unmistakable  symp- 
toms; and  again  on  April  26th,  when  a  child  of  twelve  who  had 
been  injected  with  400  units  22  days  before  broke  down.  May 
7th  an  interne  and  two  nurses  and  one  child  (all  non-imm.unized) 
came  down. 
*Probably  on  account  of  a  temporary  deficiency  of  serum. 


MORRILL.-FOR  WHAT  PERIOD  OF  TIME  <;AN  IMMUNITY,  ETC.        jgg 

Since  April  26,  1896,  from  250  to  500  units  (in  accordance 
with  agef)  have  been  given  each  case  every  three  weeks,  and 
we  have  had  no  further  trouble.  Whether  any  of  the  patients 
have  bacillary  mucous  membranes  we  do  not  know;  but  judging 
by  our  previous  experience,  some  of  them  probably  have — just 
a  certain  percentage  of  children  one  sees  playing  about  the 
streets  have. 

Since  November,  1896,  of  423  cases  immunized  every  28  days, 
three  contracted  diphtheria,  the  minimum  time  elapsed  be- 
tween the  infection  and  clinical  symptoms  being  28  days;  while 
of  non-immunized  children  and  adults  four  contracted  the  dis- 
ease. Of  680  who  have  been  immunized  every  three  weeks 
none  have  had  it.  J 

Glancing  back  over  what  I  have  said,  it  will  be  seen  that  of 
1, 80S  patients  immunized  at  least  once  every  28  days  with 
amounts  ot  serum  varying  from  150  to  500  units,  seven  had 
diphtheria;  three  from  insufficient  dosing,  two  within  twenty- 
four  hours  of  being  injected,  and  two  in  whom  the  time  of  in- 
fection came  23  and  22  days  respectively  after  being  given  an 
amount  which  has  thus  tar  proved  entirely  effective  when  given 
every  three  weeks.  Of  829  who  were  given  no  antitoxin,  or  in 
whom  more  than  28  days  elapsed  after  the  injections,  nine  had 
diphtheria,  besides  three  non-immunized  adults. 

In  New  York  the  results  as  set  forth  by  Dr.  Hermann  M. 
Biggs*  are  strongly  corroborative  of  the  views  which  our  expe- 
rience has  led  us  to  adopt:  In  the  New  York  Infant  Asylum, 
between  September,  1894,  and  January  19,  1895,  there  were  107 
cases  of  diphtheria.  Two  hundred  and  thirty-four  children 
were  immunized  on  January  17th,  and  but  one  case  occurred 
until  30  days  had  elapsed,  when  five  more  developed  during  the 
succeeding  12  days  at  which  time  an  increased  dose  (125  to  225 
units)  was  given  245  children,  and  no  further  trouble  was  ex- 
perienced for  31  days.  At  the  Juvenile  Asylum  12  cases  oc- 
curred during  the  two  months  preceding  April  13,  1895,  when 
8r  children  were  immunized   during   that,  and    the   succeeding 

tThe  patients  at  the  Boston  Children's  Hospital  are  from  two  to  twelve 

years  of  age,  inclusive. 
^Immunization  has  been  carried  out  this  summer. 
*Loc.  cit. 


J  go        MORRILL.— FOR  "WHAT  PERIOD  OF  TIME  CAN  IMMUNITY,  ETC. 

few  weeks, f  and  the  only  cases  of  diphtheria  which  developed 
were  those  of  two  non-immunized  children  and  one  adult. 
Similar  experiences  were  had  at  the  Nursery  and  Child's  Hos- 
pital, the  Bellevue  and  the  Catholic  Protectory.  At  the  last- 
named  institution  the  amounts  injected  at  the  second  immuniza- 
tion corresponded  very  closely  to  those  which  we  now  employ, 
and  no  cases  occured  within  30  days,  excepting  one  which  ap- 
peared within  twenty-four  hours  of  the  injection.  The  inspectors 
of  the  health  department  immunized  232  persons,  and  in  three  of 
the  four  cases  which  broke  down  within  the  succeeding  30  days, 
the  symptoms  appeared  within  twenuy-four  hours — examples  of 
the  unavoidable. 

Of  1,043  cases  tabulated  in  Dr.  Biggs's  report  (a  large  per- 
centage having  had  positive  cultures  and  all  having  been  more 
or  less  exposed  to  infection)  three  only,  aside  from  those  in 
which  symptoms  were  obscured  within  twenty-four  hours,  broke 
down — on  the  12th,  17th  and  i9thda)'S  respectively ;  and  in  these 
three  cases  the  dose  administered  varied  "from  10010250  units" 
examples  of  insufficient  dosage — while  at  the  Catholic  Protectory 
(where  only  one  break-down  and  that  within  twenty-four  hours 
occurred)  much  larger  quantites  were.  Surley  these  results  are 
enough  to  prove  that  there  "is  something  in"  immunization — 
something  which  not  only  saves  life,  bat  does  so  with  a  degree 
of  certainty  which  vaccination  alone  can  rival. 

Dr.  Kassowit  bases  his  theory  of  the  utter  futility  of  immuniza- 
tion partly  upon  the  fact  that  the  disease  itself  confers  no  immu- 
nity from  early  or  late  reinfection  even  in  cases  treated  with  the 
serum,  and  partly  on  cases  which  he  quotes  when  antitoxin  has 
failed  to  ensure  safety.  As  to  reinfection  after  diphtheria,  I  am 
perfectly  willing  to  concede  that  there  is  scarcely  a  disease  which 
a  human  being  cannot  have  a  second  time  if  he  survive  the  first 
attack;  and  as  to  his  instances  of  quick  relapse  after  the  serum 
treatment  it  must  be  asked  if  they  may  not  have  been  due  to 
failure  to  use  a  sufficient  quantity  during  the  original  seizure. 

The  cases  which  he  cites  as  proving  that  antitoxin  administered 
to  healthy  children  confers  no  immunity  are  for  the  greater  part 
quoted  without  reference  to  the  journals  in  which  they  were  or- 
iginally published, and  without  stating  the  number  ol  days  elap- 
tlnterval  between  injections  not  stated. 


iV[OERILL.-FOR  WHAT  PERIOD  OF  TIME  CAN  IMMUNITY,   ETC.  igi 

sing  before  infection  took  place— thus  rendering  fair  criticism 
impossible.  Of  the  few  he  mentions  with  definite  references, 
some  have  proved  inaccessible  to  me,  but  in  any  event  his  cases 
include  twelve  brothers  and  sisters  who  accompanied  diphtheritic 
children  to  the  hospital,  and  were  each  injected  with  120  units — 
three  of  those  who  were  given  this  insufficient  dose  had  diphtheria 
at  some  indefinite  time  later  on.  Two  cases  in  which  infection 
took  place  in  twenty-four  hours,  and  which  merely  substantiate 
the  fact  that  one  can  immunize  too  late.  One  case  in  which  an 
inadequate  dose  (150  units)  was  followed  by  infection  on  the  i8th 
day.     One  case  in  which  there  was  infection  on  the  aSth  day. 

I  do  not  wish  to  be  understood  as  implying  that  the  cases 
which  I  have  not  read  in  their  original  sources  of  publication  may 
not  carry  a  degree  of  belief  in  Dr  Kassowitz'  theory.  To  do  this 
would  be  to  question  the  good  faith  which  doubtless  inspired  him 
to  publish  his  articles.  I  can  only  say  from  the  material  at  my 
command,  and  an  experience  of  nearly  three  years  in  this 
special  line,  I  can  arrive  at  nothing  but  a  total  disagreement 
with  his  expressed  opinion. 

So  farfas  bad  results  from  the  injections  are  concerend, 
the  only  cases  which  I  have  seen  where  anything  like  dan- 
gerous symptoms  appeared  were  those  of  a  boy  with  asplenic 
leucocythemia,  and  another  with  a  nephritis.  In  the  latter 
instance  the  antitoxin  caused  a  distinct  increase  of  the  albu- 
minuria and  dropsy.  In  another  case  in  which  the  same 
clinical  symptoms  were  present  and  the  urinary  analysis  corres* 
ponded  very  closley  to  that  of  the  first,  the  injections  produced 
no  unpleasant  effects.  We  have  given  in  all  about  3,000  injec- 
tions;and  with  the  above  exceptions,  aside  from  an  occasional 
urticaria  (far  more  rare  now  than  formerly)  and  an  insignificant 
and  transitory  albuminuria, nothing  worth  noting  has  followed 
them.  Very  rarely  has  the  antitoxin  been  omitted  or  postponed, 
no  matter  how  sick  the  patient  may  have  been.  In  one  instance 
of  very  severe  cercbro-spinal  meningitis  in  which  no  injections 
were  given, the  child  contracted  a  diphtheria  which  proved  fatal. 

I  am  quite  sure  that  the  fact  of  our  ability  to  confer  safety  for  a 
definite  time  by  promptly  injecting  exposed  cases  with  an  ad- 
equate dose  of  antitoxic  serum  is  not  sufficiently  recognised  ;  and 
I  think  that  the  prevailing  opinion  among  the  medical  profes- 
sion regarding  immunization  may  be  stated  as  follows:    It  is  an 


1 02         MOKKILL.-rOR  WHAT  PERIOD    OF  TIME  CAN    IMMUNITY,   ETC. 

uncertain  thing  at  best,  and  perhaps  it  is,  upon  the  whole,  just  a 
well  to  watch  exposed  cases,  and  inject  promptly  the  first  mo- 
ment that  symptoms  of  diphtheria  appear.  Should  advice  of  this 
kind  be  given  as  regards  vaccinating  persons  exposed  to  small- 
pox it  would  be  just  as  logical — yet  these  principles  are  printed, 
preached  and  practised  today,  and  the  point  that  it  is  an  obvious 
duty  to  immunize  every  person  who  has  been  exposed  to  diph- 
theria is  either  denied,  dodged  by  half-hearted  approval, and  the 
recommendation  of  insufficient   doses. 

From  actual  experience  we  are  perfccty  justii'ied  in  believing: 
(i)  That  immunity  in  any  given  case,  of  no  matter  how 
thorough  exposure  to  diphtheria,  may  be  conferred,  for  at 
le:ist  ten  days,  by  the  injection  of  a  small  dose  (100-250  units) 
of  serum,  provided  it  is  given  twenty  four  hours  previous  .to 
actual  infection. 

(2)  That  a  larger  dose  (250  units  for  a  child  of  tu'o,  up  to  500 
units  for  one  of  eight  or  over)  will  confer  safety  for  three  weeks 
— or  to  be  a  little  more  conservative,  let  us  say  twenty  days — - 
under  similar  conditions. 

(3)  That  no  harm  will  result  from  the  treatment  in  a  vast 
majority  of  cases  of  sick  children,  and  probably  in  no  case  of  a 
healthy  child,  provided  the  scrum  used  is  up  to  the  present 
standard  of  purity. 

In  conclusion,  I  v/ould  say  that  any  one  who  thinks  that  anti- 
toxin w^ill  prevent  the  occurrence  of  a  follicular  tonsilitis  or  of  a 
'  coryza  in  an  individual  who  happens  to  have  the  Klebs-Loffler 
bacillus  in  his  throat  or  nose  will  be  disappointed  ;  for  neither  of 
these  conditions  constitutesa  diphtheria  any  more  than  the  coex- 
istence of  the  pneumococcus  in  the  saliva  and  a  bronchitis  con- 
stitutes a  frank  pneumonia.  I  will  add  that  a  physician  who 
fails  to  promptly  immunize  the  members  of  a  family  or  close  com- 
munity in  which  diphtheria  breaks  out,  neglects  to  do  his  duty 
by  those  whose  safety  lies  in  his  hands. — Boston  Med.  Surg.  Jour. 


NORTH  CAROLINA  MEDICAL  JOURNAL. 

ROBERT  D.   JEWETT,  M.D.,  Editor. 

DEPARTMENT  EDITORS. 

(      H.  T.  Bahnson,  M.D.,  Salem,  N.C. 
SURGERY:     -      R.  L.  Gibbon, M.D.,  Charlotte,  N.  C. 

f      J.  Howell  W  ay,  M.D.,  Waynesville,  N.  C. 

NERVOUS  DISEASES:— J  .llison  Hodges,  M.D.,  Rcihmond,  Va. 

PRACTICE  OF  MEDICINE.  \    ^-  ^^'!^^?^^.,?^™;^'  ^^•^•'  ^-  ^-  N"' 
i  Asheville,  N.  C. 

^RQTPT-RTrc;-       ^      GEORGE  G.  THOMAS,  M.D.,  Wilmino^ton,  N.  C. 
^h,bii.iKiCb.      -^     R.  L.  Payne,  M.D.,' Norfolk,  Va. 

(      H.  S.  LOTT,  M.D.,  Winston,  N.  C. 
GYNAECOLOGY:      -      J.   W.  Long,  M.D.,  Salisbury,  N.  C. 
(      H.  A.  ROYSTER,  M.D.,  Raleigh,  N.  C. 

PATE[OLOGY:— Albert  Anderson,  M.D.,  Wilson,  N.  C. 
PEDIATRICS:— J.  W.  P.  Smithwick,  M.D.,  La  Grange,  N.  C. 
TRANSLATION  AND  FOREIGN  REVIEWS: 
Richard  H.  Whitehead,  M.  D.  ,  Chapel  Hill,  N.  C. 

All  communications,  either  of  a  literary  or  business  nature,  should  be 
addressed  to,  and  any  remittances  by  P.  O.  Order,  Draft  or  Registered  Let- 
ter, made  payable  to  Robert  D.  Jkvvett,   M.D.,  Winston,  N.  C. 

Ebitorial. 


THE  SURVIVAL  OF  THE   FITTEST. 


In  these  days  of "  progress  and  rapid  advancement"one  often 
sees  the  old  tried  friend  pushed  aside  and  the  new  man,  the  man 
of  modern  ideas,  set  up  in  his  place,  and  the  sight  cannot  fail  to 
bring  a  feeling  of  sadness  and  of  wonder  at  the  ways  of  men. 
The  editor  of  the  Ho^  Spritigs  Medical  Journal  has  portrayed  in 
such  a  forcible  manner  this  phase  of  19th  century  character  that 
we  cannot  refrain  from  copying  a  portion  of  his  remarks. 
After  referring  to  the  passing  of  the  American  Indian,  the  put- 
ting aside  of  the  old  horse  worn  out  after  years  of  faithful  service 
and  of  the  faithful  dog,  who  in  his  own  way  has  done  his  part  to 


194  EDITORIAL. 

add  to  his  master's  pleasure,  he  goes  on  to  show  that  even  the 
lawyer,  the  friend,  and  the  minister  must  share  in  the  common 
fate  of  those  who  are  not  "up-to-date." 

"And  the  doctor!  What  of  him  in  the  pitiless  operations  of  this 
law?  Surely,  he  may  escape  it!  No,  indeed.  He  feels  its  force 
probably  before  the  old  lawyer  or  the  old  friend.  He  may  have 
spent  his  best  days  and  nights  in  ministering  to  the  wants  and 
whims  of  his  clientele.  He  has  answered  their  calls  at  all  times, 
gone  to  them  through  the  storms,  and  snows,  and  floods,  and 
when  the  sun  was  a  firey  furnace.  In  pestilence,  he  has  stood 
by  them.  He  has  ushered  into  the  world  the  children  of  the 
family,  has  saved  the  lives  of  these  children  in  some  dreadful 
sickness,  has  borne  them  upon  his  heart  and  in  his  brain,  and 
known  no  rest  until  the  burning  fever  was  assuaged  and  the 
glow  of  health  was  mantling  again  their  cheeks.  He  has  snatch- 
ed the  mother,  maybe  from  an  untimely  grave,  or  the  father,  the 
bread-winner,  has  been  enabled  to  go  back  to  labor  with  a  glad 
heart  and  vigorous  frame.      The  invalid  wife  iias 

"The  bright  flush  of  health  mantling  high  on  her  cheeks," 
and  grows  fat  and  strong.  And  all  this  because  of  the  judgment 
and  skill  of  some  humble  disciple  of  ^sculapius.  One  would 
think,  surely  this  man  is  exempt!  As  man  and  as  physician, and 
as  friend,  surely  he  is  not  bound  to  this  dreadful  juggernaut, 
to  be  ground  to  pieces  in  its  awful  progress!  Yes,  though  he  is 
friend  and  physician,  he  must  feel  its  crushing  effects.  He,  too, 
must  see  his  clientele  forsake  him  for  another  who  pleases  the 
fancy  or  tickles  the  palate.  The  woman  who  has  looked  into  his 
eyes  with  tears  of  gratitude  in  hers,  gratitude  for  the  life  of  a  hus- 
band or  child,  snatched  as  it  were  from  the  grave,now  meets  his 
look  coldly  as  he  passes  by.  Maybe  her  own  health  has  been  re- 
stored by  this  humble  doctor,  and,  instead  of  praises,  she  now 
speaks  of  him  as  "too  old, "or  "his  medicines  are  to  strong,"  and 
she  has  gone  off  to  somepathy,  or  some  new  and  wonderful  man 
has  arrived  in  town,  and  the  true  and  tried  man  loses  his  busi- 
ness and  his  friends  at  one  lell  swoop.  We  have  all  seen  the  old 
doctor,  ripe  in  years  and  experience,  deserted  by  those  whom  he 
has  saved,  and  left  to  nearly  starve  in  a  land  of  plenty.  The 
beautiful  tribute  Talmage  paid  to  his  family  physician  is  not  in 
their  hearts." 


EDITORIAL.  J     - 

To  prepare  himself  foi  such  a  time  Dr.  Jelks  admonishes 
phycisians  to  cultivate  more  carefully  the  business  side  of  life ; 
see  that  your  accounts  are  collected  promptly ;  lay  by  you  in  store 
for  that  rainy  day,  when  even  if  your  friends  stick  to  you  your 
physical  conditions  will  cause  you  to  lay  down  the  spatula  and 
scalpel ;  and  when,  like  the  old  horse  who  has  fufilled  his  mission, 
you  may  not,  otherwise,  find  a  pasture  wherein  you  may  graze. 
For  the  man  of  small  means  we  know  of  no  better  investment 
than  the  modern  life  insurance  policy,  which  for  a  nominal  sura 
per  annum  provides  for  a  man's  family  in  case  of  his  death  and 
for  his  own  old  age  in  case  of  his  continued  living.  Reader,  if 
you  have  no  certain  provision  for  your  family  and  your  own  old 
age,  let  it  be  one  of  your  new  year  resolutions  to  invest  some- 
thing in  this  way  at  once.  If  your  income  will  not  permit  you 
to  take  a  policy  for  $10,000,  or  $5,000,  then  take  one  for  $3,000 
or  even  $1,000,  payabe  to  yourself  at  the  end  of  ten  or  twenty 
years,  and  to  your  family  in  case  of  your  earlier  death.  Old 
age  may  come,  and  death  must;  don't  let  them  find  you  unpre- 
pared. 


THE  SOCIETY  MEETING. 


We  beg  to  to  remind  members  of  the  Society  that  only  a  little 
more  than  a  month  intervenes  between  this  and  the  time  of 
meeting.  The  meetings  at  Charlotte  are  alvvays  good — it  is  a 
point  easily  reached,  the  hotel  accommodation  is  good  and  ample, 
and  the  hospitality  of  the  people  knows  no  bound.  There  is 
every  reason  to  believe  then  that  the  coming  meeting  on  the  3rd, 
4th,  and  5th,  of  May,  will  be  one  of  the  most  successful  in  the 
history  of  the  Society.  Members  intending  to  read  papers  are 
reminded  that  it  is  time  the  titles  of  their  papers  were  in  the 
hands  of  the  secretary.  We  would  also  suggest  that  writers  of 
papers  secure  the  promise  from  one  or  two  of  their  friends  to 
open  the  discussion  on  their  papers.  Many  times  a  valuable 
papers  falls  flat  and  loses  much  its  usefulness  because  every  one 
waits  for  some  one  else  to  start  a  discussion  of  the  subject.  One 
member  making  a  few  remarks  is  often  the  signal  for  a  wide  and 


jgg  CURRENT   LITERATURE. 

valuable  expression  of  the  views  of  members  present.  The  great 
value  of  the  Society  meetings  is  in  this  interchange  of  views 
and  experiences,  for  the  opinion  of  the  writer  alone  can  be  just 
as  well,  or  better,  obtained  by  a  quiet  reading  of  his  essay  after 
its  publication  in  the  Journal  or  the  Transactions.  We  would, 
therefore,  insist  on  the  great  advantage  of  each  author  secur- 
ing some  particular  member  to  open  a  discussion  on  his  paper. 
The  addre':';  of  the  Secretary  has  been  changed  from  Wil- 
niingtou  to  Vv'inston,  N.  C. 


The  Removal  of  the  Journals  Plant  and  its  rearrangement 
causes  an  unavoidable  delay  in  the  appearance ol  this  issue.  We 
ask  our  readers  to  bear  with  us  this  time,  promising  that  the 
next  issue  will  appear  on  time. 


IReview  of  Current  Xiterature. 


GYNECOLOGY  AND  ABDOMINAL  SURGERY. 

IN  CHARGE  OF 

H.  S.  LoTT,  M.  D.,  J.  W.  Long,  M.  D., 

Hubert  A.  Royster,  M.  D. 


Endometritis  Chronica.— F.  J,  Sharp  (Brooklyn  Med.  Jour., 
March  1898 )  writes  an  interesting  and  practical  paper  on  this  very 
common  gynecolog-ic  complaint.  Its  pathology  receives  due  attention. 
The  scope  of  Ms  article  was  confined  to  the  disease  in  its  simple  form 
and  "as  it  occurs  in  common  with  laceration  of  the  cervix."  Treat- 
ment: in  mild  cases,  applications  of  carbolic  acid  or  iodized  carbolic 
paste  to  the  interior  of  the  uterine  canal,  followed  by  antiseptic 
douches;  in  the  severer  forms,  thorough  curettage,  under  strict  anti- 
septic precautions,  followed  by  antiseptic  applications  and  douches; 
puncture  nabathian  follicles  and  repair  any  deep  cervical  lacerations. 
He  considers  that  a  slight  laceration  does  not  interfere  with  resolution. 

H.  A.  R. 


CURRENT   LITERATURE.  jg- 

SupRA-PUBic  VS.  Vaginal  Section  in  Pelvic  Pus  Accumula- 
tions.—T.  A.  Ashby  ( Bulletin  of  the  Maryland  Univ.  Hosp.,  Feb. 
1898)  presents  the  pros  and  cons  of  this  question  concisely  and  fairly. 
He  divides  the  subject  into  three  heads,  viz.,  first,  the  advantages  of 
the  supra-pulvic  route;  second  the  value  of  the  vaginal  route  and  third, 
the  general  indications  which  should  lead  to  the  adoption  of  the  one  or 
the  other.     His  argument  may  be  summarized  as  follows: 

1.  The  abdominal  route  "admits  of  careful  inspection,  dissection, 
evacuation  and  repair  of  invaded  tissues" — i.e.,  ''a  completed  opera- 
tion," and  yet  is  conservative  in  its  tendency. 

2.  The  vaginal  route  possesses  one  great  advantage — the  matter  of 
drainage,  '"It  is  more  accessible,  less  dangerous  and  will  often  per- 
mit of  the  removal  of  pus  accumulations  when  encysted  and  closed  off 
from  the  peritoneal  cavity." 

3.  The  vaginal  method  may  be  chosen  when,  wdth  a  bilateral  salpyn- 
gitis  and  an  infected  uterus,  it  is  considered  proper  to  do  a  total  ex- 
tirpation; the  abdominal,  when  only  one  ovary  or  tube  is  involved  or 
where  the  diagnosis  cannot  be  sufficiently  clear. 

The  author  is  distictly  a  supraipubic  operator  and  thinks  that,  in 
America,  where  abdominal  surgery  had  its  birth,  this  method  "has 
more  than  held  its  own  against  the  assaults  made  by  the  French  school 
of  vaginal  sectionists."  H.  A.  R. 

Conservative  Surgery  of  the  Uterine  Appendages.— A.  P. 
Dudley  ( Amer.  .Jour.  Obstet.  Jan.  1898)  chooses  this  subject  to  answer 
criticisms  and  to  show  the  results  of  his  work  for  the  past  ten  years. 
He  thinks  the  pendulum  has  swung  too  far  and  that  many  organs  are 
unnecessarily  removed  from  the  pelves  of  women,  deprecating  emphat- 
ically the  frequent  performance  of  hysterectomy — an  operation  stim- 
ulated to  a  certain  extext  by  fashion.  The  author  then  proceeds  to 
answer  the  question  "To  what  extent  can  we  do  conservative  surgery 
upon  the  uterine  appendages  with  safety  to  the  patient?"  by  a  running 
account  of  his  own  cases  and  a  summing  up  of  his  results.  In  88  cases 
he  removed  portions  of  tubes  and  ovaries  and  returned  the  remaining 
portion  of  the  appendage  to  the  pelvis.  The  after  history  of  all  was 
not  obtainable  but  14  of  them  subsequently  beca,me  pi-egnant,  while, 
out  of  the  whole  88  cases,  secondary  inflammatory  disturbance  followed 
in  only  one— which  was  gonorrhceal  in  origin.  The  rule  in  operating 
on  the  ovary  was  to  save  all  of  the  organ  possible.  He  has  cross-sec- 
tioned it  and  sewed  it  together  (ahvays  using  fine  silk);  taken  V-shaped 
pieces  out  and  closed  the  edges;  punctured  cystic  ovaries  through  and 
through;  cut  them  completely  in  two  longitudinally,  removed  cysts 
from  the  centre  and  stitched  them  up  again;  evacuated  pus  from  the 
ovary  and  left  the  healthy  portion  behind;  removed  almost  the  entire 
ovary,  leaving  a  very  small  part  (size  of  pea)  and  fastened  that  to  the 
end  of  the  tube.  The  fallopian  tuba  he  has  treated  conservatively  for 
various    forms  of    disease.     He  opens  up  occluded  tubes   and  always 


jgg  CURRENT   LITERATURE. 

Stitches  che  mucous  lining  to  the  peritoneal  coat,  after  slitting  it  upon 
the  upper  surface  and  everting  it— in  the  manner  of  a  phimosis  opera- 
tion. He  has  incised  a  pj^o-salpynx,  washed  out  the  pus  with  an  asep- 
tic solution,  after  passing  a  probe  through  the  tube  into  the  uterus, 
thus  dilating  the  tubo-uterine  stricture,  and  has  had  his  patients  re- 
cover without  the  first  signs  of  peritonitis.  He  adds,  however,  that  he 
never  treats  a  tube  in  this  manner,  if  there  be  any  odor  to  the  pus 
showing  internal  gonorrhjeal  or  septic  inflammation.  The  author  con- 
cludes v.ith  two  reasons  for  his  devotion  to  such  work: 

1.  The  inability  to  anticipate  or  estimate  the  effect  of  an  earlj'  in- 
duction of  the  menopause  on  a  woman's  nervous  system — possibly, 
personal  suffering  and  domestic  unhappiness. 

2.  ''Pelvic  surgery  should  not  be  compassed  about  by  the  opinion 
even  of  a  majority  of  the  profession.  Hysterectomy  is  the  last  resort 
to  effect  a  cure."  The  prediction  is  expressed  that  if  any  advancs  is 
made  during  the  next  10  years,  it  will  be  along  this  line  of  conserva- 
tive surgery  upon  the  appendages.  H.  A.  R. 


GENERAL  SURGERY. 

IN  CHARGE  OF 

H.  T.  Bahnson,  M.D.,  R.  L.  Gibson,  M.D. 

J.  Howell  Way,  M.D. 


The  First  Care  of  the  Injured  in  Railway  Accidents.— The 
above  is  the  title  of  a  very  excellent  paper  by  Dr.  B.  R.  "Wilson,  (The 
International  Jour.  Surg. )  from  which  the  following  conclusions  are 
derived: 

1.  Stop  hcemorrhage  by  ligating  vessels  an'  applying  compresses 
and  bandages. 

2.  Treat  shock  by  stimulants,  both  alcoholic  and  with  strychnia  and 
nitroglycerine. 

3.  Relieve  pain  by  the  hypodermatic  use  of  morphia,  and  local  ap- 
plications of  cocaine,  antipyrine,  acetanilide,  and  exclude  air, 

4.  Reduce  dislocations  at  once,  coaptate  broken  bones,  and  retain 
them  in  place  by  any  appliances  that  will  temporarily  prevent  motion 
of  the  injured  part  as  much  as  possible. 

5.  Dress  all  wounds  temporarily  with  gauze,  cotton  or  clean  waste 
and  bandages. 

6.  Transport  the  patient  to  the  hospital  or  some  other  place  as  soon 
as  possible,  and  with  as  much  comfort  as  it  is  possible  tD  obtain  under 
the  circumstances. 


CURKINT  LITEKATII.F. 

7.  Do  not  perform  any  capital  operation  while  the  patient  is  suffer- 
ing- from  shock,  exercise  your  best  judgment,  however,  and  give  the 
patient  the  benefit  of  the  doubt.  J.  H.  W. 

Surgical  Treatment  of  Tuberculous  Bone  Disease.— Cabot, 
(Boston  Med.  and  Surg.  Jour..  Jan.  27,  1898).  In  cases  of  local  Tuber- 
culosis the  tissues  make  an  effort  to  protect  themselves  by  throwing  up 
a  wall  of  connective  tissue  about  the  focus  of  infection,  thus  encapsu- 
lating it.  The  success  of  this  limiting  eft'ort  on  the  part  of  the  tissues 
depends  in  a  considerable  degree  upon  the  vigor  of  the  individual. 
In  many  instances  the  surgeon's  reliance  must  be  upon  this  power  of 
nature,  simply  directing  his  attention  to  the  general  condition  of  the 
patient  and  affording  rest  to  the  diseased  part.  As  tuberculosis  of 
bone  is  generally  secondary  to  some  deeper  infection,  its  removal  is 
only  palliative,  the  deeper  infection  remaining.  The  primai-y  infection 
having  been  encapsulated,  a  return  to  health  may  often  be  expected  if 
the  local  infection  can  be  thoroughly  removed  without  bringing  the 
tuberculous  parts  into  contact  with  the  healthy.  This  is  rarely  possi- 
ble in  tuberculosis  of  bone,  and  especially  of  joints;  for  the  infected 
synovial  membrane  is  often  very  difficult  of  I'emoval,  as  it  dips  in  be- 
tween the  ligaments  and  the  surrounding  muscles  and  must  be  dis- 
sected away  piece-meal.  Fortunately,  however,  the  tissues  are  able  to 
dispose  of  of  a  moderate  dose  of  the  poison.  In  the  removal  of  tuber- 
culous bone  a  considerable  quantity  of  the  surrounding  bone  should 
be  taken  away  with  it,  when  possible.  This  is  done  in  resections  of 
the  knee  and  elbow,  and  of  the  hip  when  the  disease  is  confined  to  the 
head  of  the  femur.  In  disease  of  the  long  bones  where  removal  of  por- 
tions of  the  bones  would  destroy  the  function  of  the  member,  the  sur- 
geon has  to  depend  upon  curetting.  The  diseased  bone  being  soft  can 
usually  be  quite  thoroughly  removed  with  the  sharp  spoon,  the  hard 
healthy  bone  giving  a  very  good  idea  as  to  the  amount  to  be  removed. 
After  such  an  operation  it  is  not  uncommon  to  see  the  surface  curetted 
remain  in  a  carious  condition  for  some  little  time.  This  is  due  to  a 
death  of  the  surface  of  the  bone  bruised  by  the-  instrument.  And  in 
some  cases  the  presence  of  the  tuberculous  process  reinfects  the  bone 
and  leads  to  a  continuance  of  the  tuberculosis. 

In  the  carpus  and  tarsus  this  recurrence  of  tuberculosis  is  almost 
certain  to  occur.  This  is  doubtless  due  in  part  to  the  comparatively  • 
ill-nourished  condition  of  these  bones.  Surrounded  as  they  are  by 
cartilaginous  joint-surfaces,  their  periosteal  envelope,  through  which 
they  receive  nourishment,  is  comparatively  scanty.  It  is  usually  well, 
therefore,  to  wholly  remove  any  of  these  bones  that  are  diseased. 

It  is  often  a  nice  question  of  judgment  whether,  in  a  certain  patient, 
to  choose  a  partial  operation,  as  the  removal  of  the  diseased  tarsal 
bones,  for  instance,  or  to  give  up  any  attempt  to  save  the  joint  and 
Accomplish  a  thorough  removal  of  the  tuberculous  parts  by  amputation. 

As   regards  the   success  of  the  treatment,  the  older  the  patient  the 


2  00  THERAPEUTIC  HINTS. 

worse  the  prognosis.  It  ia  of  the  greatest  importance  to  get  the  pa- 
tient out  of  bed  and  out  of  doors  as  speedily  as  possible.  In  regard 
to  after  treatment  of  the  local  condition,  we  should  give  the  part  abso- 
lute rest,  and,  if  possible,  apply  gentle,  even  pressure  over  the  whole 
seat  of  disease.  Iodoform  has  a  specific  effect  opon  tuberculous  mate- 
rial. In  a  case  of  extensive  cavity  it  is  usually  applied  in  the  form  of 
iodoform  gauze  or  by  means  of  setons,  which  are  very  useful  in  the 
ankle  and  wrist-joints.  In  sinuses  iodoform  oil  afTorda  a  good  means 
of  applying  the  drug  to  the  deeper  parts  an^.  oiten  excellentresuits  are 
obtained. 


vlbcrapcutic  l^inta. 


Acute  Catarrhal  Bkoxchitis: 

I^ — Potassium  Citrate rss; 

Apomorphin  Hydrochlor.    .      .      .  gr.  i; 

Syr.  Ipecac j  ss  ; 

Lerpon  Juice 3  ij ; 

Simple  Syrup  sufficient  to  make  .  3  iv. 

M.  Dose. — Tablespoonful  in  water  every  3  hours. — Wood. 
Phil.  Med.  Jour. 

The  Treatment  of  Coryza  in  Childhood. — Daucher  gave 
the  following  directions  to  a  ten-year  old  child  with  lymphatic 
habitus  and  inclination  to  struma: 

1.  Every  morning,  on  awakening,  the  nasal  cavities  are  to  be 
thoroughly  washed  out  with  a  sponge  or  napkin  wet  in  a  luke- 
warm solution  of  common  salt. 

2.  After  a  few  days  this  irrigation  is  replaced  by  one  contain- 
ing a  10-20  per  cent,  solution  of  alum.  If  headache  is  severe, 
the  child  is  to  inhale  every  two  hours  the  steam  from  the  fol- 
lowing mixture: 

5 — Chloroformi 5.0 

^ther  suifur 15.0 

01.  terebinth 3.0 

M.  D.  S. — For  external  use. 

These  inhalations  are  to  act  as  anodyne  and  revulsive,  but 
not  as  a  narcotic. — Die  Therapie  d.  Gegenwart. — Pediatrics. 


NOTKS  AND   ITEMS.  201 

Diphtheria  Antitoxin  by  thk  Stomach. — Dr.  J.  Lindsey 
Porteoiis,  of  Yonkers,  N.  Y.,  reported  a  number  of  microscopi- 
cally proven  cases  of  diphtheria  to  the  Neiv  York  Medical 
Record,  of  December  25th.  The  cases  were  severe  and  demanded 
the  antitoxin  treatment,  which  Dr.  Porteous  gave  them,  admin- 
istering the  remedy  by  the  stomach  instead  of  hypodermically 
as  has  heretofore  been  the  universal  cu  tom.  Every  case  re- 
covered and  showed  the  prompt  action  of  the  antitoxin  as  plainly 
,as  if  it  had  been  given  under  the  skin. 

The  doctor  concludes:  "If  this  mode  of  administration  has 
been  tried  before,  I  am  not  aware  of  it.  My  object  in  writing 
these  notes  is  to  prove  that  the  antitoxin  of  diphtheria  is  not 
rendered  inert  by  changes  in  the  stomach,  and  that  this  is  an 
easy  method  of  giving  it  to  nervous  children." 

Alopecia  : 

I^ — Tr.  Canthar 3  iv. 

Tr.  Capsici 3  i. 

01.  Ricini 3  iss. 

Alcoholis    q.  s.  ad.     ...       3  iv. 

M.      Sig. — Use  as  a  lotion. — Med.  a?id  Surg.  Rep. 


IRotee  anb  litems. 


A  Western  newspaper  threatens  to  publish  the  name  of  the 
attending  physician  in  each  case  where  the  patient  dies. 

The  Medical  and  Surgical  Reporter,  of  Philadelphia,  is  now 
published  semi-monthly  instead  of  weekly.  It  appears  in  en- 
larged and  improved  form.  We  trust  it  will  always  continue 
to  be  as  good  as  it  has  been  for  some  years  past. 

A  sad  event  happened  recently  in  the  Catholic  Hospital  at 
Heme,  in  Westphalia.  A  man  who  had  received  a  gunshot 
wound  of  the  abdomen  was  brought  to  the  hospital  and  was, 
of  course,  at  once  operated  on.  The  operation  was  very  diffi- 
cult and  chloroform-administration  had  to  be  kept  up  for  about 
four  hours.       Gas   was   the   illuminan"    used    in    the   operating 


202  NOTES    AND  ITEMS. 

room,  and  it  appeared  that  the  gaslight  decomposed  the  chlo- 
roform with  evolution  of  powerful  chlorinated  vapors  which 
overcame  the  two  surgeons  and  the  Sisters  of  Mercy.  One  of 
the  sisters  died  on  the  second  day  and  the  lives  of  the  others 
were  in  great  danger. — Lancet. 

The  MiDwivEs'  Question  in  England. — The  activity  that  we 
have  recently  noted  as  being  manifest  in  medical  circles  in 
New  York  over  a  proposal  to  restrict  or  abolish  midwives,  has 
its  exact  counterpart  just  now  in  England.  The  bill  for  the 
registration  of  midwives,  which  has  already  been  read  once  in 
the  House  of  Commons,  and  which  is  set  down  for  second  read- 
ing in  a  little  over  two  months'  time  (May  nth),  has  been  pub- 
lished, and  its  wording  and  tenor  have  produced  much  appre- 
hension in  the  minds  of  the  mass  of  English  practitioners. 
Under  this  bill,  which  has  for  its  nominal  purpose  the  securing 
to  the  parturient  poor  of  adequate  obstetric  nursing,  many 
persons  of  experience  predict  that  the  bulk  of  the  midwifery 
practice  of  the  kingdom  will  be  at  once  transferred  from  the 
hands  of  properly  qualified  physicians  and  surgeons  to  a  half- 
educated  body  of  women.  The  conviction  that  such  a  transfer 
ence  would  be  a  most  serious  danger  to  the  public,  no  less  than 
a  natural  desire  that  the  precincts  of  medicine  should  not  be 
invaded,  has,  in  consequence,  led  many  medical  men,  until  now 
ready  to  welcome  a  piece  of  legish;tion  whose  charitable  object 
seemed  to  be  beyond  suspicion,  to  fiercely  oppose  all  attempts 
to  regularize  by  law  the  position  of  the  midwife,  and  even  to 
emulate  their  more  thorough-going  colleagues  in  New  York, 
and  to  demand  the  abolition  of  midwives  as  a  dangerous  and  im- 
moral class.  The  wording  of  the  proposed  measure,  or  to  be 
accurate,  a  certain  omission  in  its  wording,  is  responsible  for 
this  widespread  distrust  of  its  designs  and  fear  of  its  conse- 
quences. For  there  is  no  clause  in  the  bill  defining  the  scope 
of  the  work  which  will  be  expected  from  the  new  midwifery 
nurses  created  under  its  provisions.  Exactly  what  a  midwifery 
nurse  or  "legal  midwive"  may  do  and  may  not  do,  is  left  en- 
tirely to  the  imagination,  and  the  medical  profession  has  elected 
to  believe  (on  very  good  grounds,  it  should  be  added)  that  she 
will  be  allowed  to  do  almost  everything.  Therefore,  the  mem- 
bers of  the  medical  profession  in  England,  save   those  who,  by 


NOTES    AND  ITEMS.  

203 

position  or  class  of  practice,  are  indifferent  to  the  matter,  or 
chiefly  concerned  in  having  under  their  hands  a  large  supply  of 
trained  obstetric  nurses,  are  becoming  daily  more  unanimous  in 
their  opinion  that  the  suggested  measure  must  not  become  law. 
The  British  Medical  Association  is  now  attempting  to  make  the 
supporters  and  opponents  of  the  bill  shake  hands  over  another 
bill.  The  bill  promoted  by  the  Association  is  an  excellent  meas- 
ure for  the  protection  of  pregnant  and  lying-in  women  and 
newly-born  children,  and  for  this  reason  should  obtain  the  full 
approval  of  the  public.  At  the  same  time,  the  Association  has 
carefully  tackled  the  awkward  question  of  what  shall  be  the 
sphere  of  the  educated  "legal  midwife,"  by  detfining  the  vari- 
ous situations,  some  twenty-four  in  number,  when  the  midwife 
must  send  for  proper  medical  aid.  It  is  possible  that  the  bill  of 
the  Association  may  prove  the  basis  of  reconciliation  between 
the  combatants. 

The  Health  of  Sir  Richard  Quain. — A  well  informed  cor- 
respondent in  London  writes  under  date  February  26th:  "Sir 
Richard  Quain,  the  President  of  the  General  Medical  Council 
of  Great  Britain  is,  I  hear,  very  ill."  It  is  an  open  secret  that 
Sir  Richard,  Vv'ho  is  82  years  of  age,  underwent  a  severe  surgi- 
cal operation  last  year — a  colotomy  for  malignant  disease — so 
that  we  are  not  surprised  to  learn  that  his  hold  upon  life  is  an 
insecure  one.  His  health  did  not  allow  him  to  preside  at  the 
last  meetings  of  the  Council,  when  his  place  was  taken  by  his 
probable  successor  as  President,  Sir  Willian  Turner  of  Edin- 
burgh.— Phil.  Med.  Jour. 

Tv.'o  Curious  "Freaks." — The  following  account  of  two 
performers  at  Barnum  &  Bailey's  Circus  at  the  Olympia  is  taken 
from  the  Lancet  oi  February  2d: 

One  of  these  entertainers,  whose  name  is  Delno  Fritz,  is  a 
sword-swallower,  and  asserts  that  he  can  swallow  longer  swords 
than  have  ever  been  swallowed  before.  We  for  our  part  never 
want  to  see  any  one  swallow  more  rigid  metel.  To  those  who 
know  the  surface  markings  of  the  abdomen  and  the  situation  of 
the  stomach  it  is  little  short  of  appalling  to  see  this  man  pass  a 
sword  down  his  gullet  until   the   hilt   impinges   upon    his  teeth 


204  NOTES    AND  ITEMS. 

and  then  withdraw  the  weapon  and  demonstrate  by  outside 
measurement  that  in  the  erect  posture  the  point  falls  some  inches 
below  the  usual  line  of  the  lower  curvature  of  the  stomach.  What 
really  happens,  of  course,  is  that  Delno  Fritz  has  lea'-ned, 
consciously  or  unconsciously,  to  stretch  the  somewhat  loose 
and  elastic  tissues  between  the  lips  and  the  cardiac  orifice  of  the 
stomach,  so  that  these  tissues  will  lie  along  his  blunted  sv/ord 
in  a  condition  of  extension,  while  a  protruded  chin  assists  in  the 
piuiougciuiwu  ui  LUC  pliarynx.  It  should  be  added  that  the  solidity 
of  the  weapon  with  which  the  feat  is  performed  is  beyond  ques- 
tion. A  second  person  in  whom  medical  men  must  be  interest- 
ed is  one  Young  Hermann,  wlio  can  expand  and  contract  his 
chest  and  abdomen  at  will  to  really  remarkable  dimensions. 
He  is  able  to  make  a  bona  fide  difference  of  sixteen  inches  in  his 
chest  measurement,  and  accordingly  to  snap  chains  and  straps 
fastened  across  his  thorax  by  the  standing  pressure  he  is  able  to 
effect  upon  them.  ■  The  alterations  which  he  produces  in  his 
abdominal  outlines  are  no  less  striking.  By  swallowing  air  and 
then  effecting  pressure  upon  it  by  contractions  of  the  rectus 
abdominis  muscle  he  can  rapidly  pass  from  the  appearance  of 
extreme  corpulency  to  the  appearance  of  horrible  emaciation, 
the  skin  of  the  abdomen  appearing  in  the  latter  case  to  lie  against 
the  spinal  column.  His  extraordinary  power  of  swallowing  and 
inhaling  air  enables  him^  to  shift  the  apex  beat  of  the  heart  many 
inches  and    otherwise  to    displace    his    viscera. 

The  power  of  swallov/ing  air  is  not  exceedingly  rare,  but  the 
extent  to  which  Young  Hermann  possesses  it  is  unexampled  in 
our  experience.  It  is  probable  that  Joseph  Clark,  the  cele- 
brated posture  maker  of  the  seventeenth  century,  possessed  the 
secret  of  this  trick  in  addition  to  his  unwholesome  knack  of 
dislocating  many  of  his  joints  at  will.  It  may  be  remembered 
that  Clark's  favorite  joke  was  to  go  to  a  tailor  to  be  measured 
with  his  right  shoulder,  say,  much  higher  than  the  left,  to  return 
to  fit  the  suit  on  with  the  protuberance  on  the  other  side,  and 
finally  to  call  at  the  shop  and  reject  the  clothes  indignantly, 
having  this  time  assumed  a  central  hump.  Young  Hermann 
might  amuse  himself  in  a  similarly  ill-natured  way  if  the  inclina- 
tion took  him. — Boston  Med.  and  Surg.  Jour. 

A  New  Amusement  Enterprise. — The  editors  of  this  journal 


NOTES   AND  ITEMS.  20c: 

recently  received  complimentary  invitation  cards,  requesting 
their  presence  at  the  Lion  Institute,  Fifth  avenue,  New  York, 
to  witness  the  following  stellar  attraction: 

Lion's  Infant  Incubators, 

Containing  Live  Babies, 

On  View  Daily,  from  lo  to  lo. 

The  manager  of  this  enterprise  is  one  of  the  Kiralfy  family, 
who,  "years  ago,  were  leading  factors  in  the  American  Amuse- 
ment World." 

Thus  do  we  evolute.  Thus  does  the  dime  museum  come  in 
touch  with  the  scientific  world.  Thus  do  these  sad  accidents, 
these  weazened,  shrivelled,  premature  babies  contribute  to  our 
entertainment.  Thus  can  Americans  be  said  to  take  their 
troubles  hilariously. 

What  may  happen  when  in  the  multiplication  of  these  amuse- 
ment enterprises,  the  supply  of  premature  births  may  not  equal 
the  demand?  Will  the  abortionist  be  called  in,  or  will  the  dime 
museum  take  a  step  higher? 

What  an  alluring  bill  of  fare  the  following  might  be: 

Doors  Open  from  lo  to  lo. 

Stomachs  Washed  Out  on  Upper  Stage  Every  Hour. 

Infants  Fed  Every  Three  Hours  on  Top  Floor. 

Osteoclasis  for  Bow-Legs  Daily  at  lo  a.m. 

(Conducted  by  Prof.  Slump). 

Special — Schlatter  Operation  To-day  at  2  p.  m. 

Transplantation  of  Skin  from  Elastic-Skin  Man   to  Every  Lady 

Holding  Reserved  Seat. 
Get    Scats    Early    for   Amphitheater — Special    Attraction — "A 
Run    With     the    Police    Surgeon" — Illustrating    Arsenical 
Poisoning  of  Dcmi-Mondaine — Real   Arsenic — Real  Dcmi- 
Mondaine.  —  Western  Med.  and  Surg.  Gazette. 

Some  "Don't"  about  Heart  Disease. — Don't  feel  called 
upon  to  give  digitalis  as  soon  as  you  hear  a  murmur  over  the 
heart.      Study  and  treat  the  patient  not  the  murmur. 

Don't  conclude  that  every  murmur  indicates  disease  of  the 
heart. 

Dont  forget  that  the  pulse  and  general  appearance  of  the 
patient  often  tell  more  than  auscultation. 

Don't  neglect  to  note  the  character  of  the  pulse  when  you  feel 


t-  PUBLIC  SERVICE. 

200 

it.  Possibly  you  iiay  look  at  the  tongue  to  satisfy  the  patient; 
feel  the  pulse  to  instruct  yourself. 

Dont  think  every  systolic  murmur  at  the  apex  indicates  mitral 
regurgitation;  every  systolic  murmur  at  the  aortic  interspace, 
aortic  stenosis.  The  former  may  be  trivial;  the  latter  may  be 
due  to  atheroma  of  the  arch  of  the  aorta. 

Dont  say  every  sudden  death  is  due  to  heart  disease. 

Don't  forget  that  the  most  serious  diseases  of  the  heart  may 
occasion  no  murmur.  A  bad  muscle  is  worse  than  a  leaky 
valve. 

D0nt  examine  the  heart  through  heavy  clothing. 

Dont%\\^  positive  opinions  after  one  examination. — Phila- 
delphia Medical  Journal. 


THE  PUBLIC  SERVICE. 


UNITED  STATES  MARINE  HOSPITAL  SERVICE. 

Bailhache,  Preston  H.,  surgeon,  to  proceed  to  Cape  Fear 
Quarantine,  Southport,  N.  C,  as  inspector.      March  8,  1898. 

Peckham,  C.  T.,  passed  assistant  surgeon,  upon  being  re- 
lieved by  Passed  Assistant  surgeon  W.  J.  S.  Stewart,  tn  pro- 
ceed to  Pittsburg,  Pa.,  and  assume  command  of  service. 
March  8,   1898. 

Pettus,  W.  J.,  passed  assistant  surgeon,  relieved  of  command 
of  service  of  Norfolk,  Va.,  and  to  remain  in  command  of  Cape 
Charles  Quarantine.      March  10,  1898. 

Magruder,  G.  M.,  passed  assistant  surgeon,  to  rejoin  station, 
Memphis,  Tenn.,  March  8,  1898. 

Wertenbaker,  C.  P.,  passed  assistant  surgeon,  to  proceed  to 
Middleboro,  Ky.,  for  special  temporary  duty.     March  10,  1898. 

Brown,  B.  W.,  passed  assistant  surgeon,  to  proceed  to  Nor- 
olk,  Va.,  and  assume  command  of  service.      March  7,  1898, 

Stewart,  W.  J.  S.,  passed  assistant  surgeon,  upon  being  re- 
lieved by  Passed  Assistant  Surgeon  G.  M.  Magruder,  to  rejoin 
station  at  Vineyard  Haven,  Mass.      March  8,  1898. 

Oakley,  J.  H.,  passed  assistant  surgeon,  granted  leave  of 
absence  for  one  month.     March  4,  1898. 

Hastings,  Hill,  passed  assistant  surgeon,  to  rejoin  station, 
New  Orleans,  La.      March  8,  1898. 

Von  Ezdorf,  R.    H.,    assistant   surgeon,   to   proceed   to  New 


NECROLOGY.  ^O^ 

Orleans,  La.,  for  duty  and  assignment   to  quarters.     March  4, 
1898. 

APPOINTMENTS. 

Rudolph  von  Ezdorf  of  the  District  of  Columbia,  and  Milton 
H.  Foster  of  Pennsylvania,  commissioned  as  assistant  surgeons. 

NAVY. 

Surgeon  L.  B.  Baldwin,  detached  from  the  Puritan,  March 
T7,  and  ordered  home  with  two  months'  leave. 

Surgeon  J.  D.  Gatewood,  detached  from  duty  at  the  Naval 
Meseum  of  Hygiene,  Washington,  D.  C,  March  15,  and  order- 
ed to  the  Puritan,  March  17. 

Assistant  Surgeon  C.  D.  Kindleberger,  detached  from  the 
Olympia,  and  ordered  home  with  two  months'  leave. 

Surgeon  N.  H.  Drake,  detached  from  duty  with  the  Minne- 
apolis and  Columbia  and  ordered  to  the  Minneapolis  March  15. 

Surgeon  C.  G.  Herndon,  ordered  to  the  Columbia  March  15. 


NECROLOGY. 


Sir  Richard  Quain,  Bart.,  physician  extraordinary  to  Queen 
Victoria  and  Editor  of  Quains  Dictionary  of  Medicine,  March 
15th,  at  the  age  of  eighty-one. 

Dr.  Jno.  Mason  Strong,  one  of  the  oldest  physicians  of  Meck- 
lenburg county,  March  11,  1898. 

Dr, Thomas  Jefferson  Moore,  aged  58  years,  at  Richmond,  Va., 
February  22,  1898,  Dr.  Moore  >/asaNorth  Carolinian,  having 
been  born  in  Charlotte,  April  30,  1840,  He  removed  to  Richmond 
in  1882,  He  was  vice  President  of  the  Medical  society  of  the 
State  of  North  Carolina  in  1882,  and  after  his  removal  to  Vir- 
inia  was  made  an  honorary  member  of  the  society. 

Dr.  William  W.  Luck,  aged  27  years,  in  Middleburg,  Va., 
February  20,  1898, 

Dr.  A,  H,  Dismond,  aged  44 years,  in  Richmond,  Va.,  March 
I,  1868. 


1Rca^ina  IRotlces* 


A  Pre- Antitoxin  Mortaly  of  40  per  cent.  Reduced  to  3.6 
PER  CENT. — Prior  to  the  introduction  of  Anti-Diphtheritic 
Serum,  the  mortality  from  diphtheria  at  the  Harper  Hospital, 
Detroit,  averaged  for  a  number  of  years  40  per  cent.  Accord- 
ing to  the  34th  annual  report  of  the  Hospital  authorities,  as 
published  in  the  February  number  of  the  Harper  Hospital  Bul- 
letin^ page  75,  141  cases  were  treated  at  the  Hospital  during 
1897,  with  the  following  results: 

Casks.      Deaths. 

Ordinary  Diphtheria 115  i 

Laryngeal  Diphtheria 26  6 

141  7 

Excluding  two  cases  Moribund  on  Admission.    2  2 

139  5 

Mortality  under  Anfitoxin  Treatment 3.6  per  cent. 

The  antitoxin  employed  exclusively  in  Harper  Hospital  dur- 
ing 1897,  was  the  Anti-Diphtheritic  Serum  of  Parke,  Davis  & 
Co. 's  Biological  Department,  and  the  remarkable  reduction  dis- 
played in  the  death-rate  reflects  the  highest  credit  on  the  effi- 
cacy of  this  matchless  product. 

Petroleum  Emulsion. — Although  the  medical  properties  of 
petroleum  have  been  known  since  a  very  early  date,  yet  it  is 
only  within  a  few  years  that  the  remedy  has  been  prominently 
brought  to  the  attention  of  the  profession.  There  can  be  no 
question  whatever  but  that  petroleum  is  an  oil  which  is  digested 
and  absorbed  like  any  of  the  fatty  foods.  The  oil  is  emulsified 
by  the  pancreatic  juices  and  absorbed  by  the  lacteals.  The 
Angier  Chemical  Co.  put  petroleum  on  the  market  in  the  form 
of  an  emulsion  because  they  believe  that  as  the  process  of  emul- 
sifying thoroughly  breaks  up  the  oil  into  minute  particles  it  thus 
predigests  it  and  puts  it  in  a  condition  so  that  it  can  be  absorbed 
at  once.  The  Angier  Chemical  Co.,  emulsion  has  combined  with 
it  the  wellknown  hypophosphites.  Each  ounce  of  the  emulsion 
contains  33^3  per  cent,  of  purified  petroleum  and  twelve  grains 
of  the  combined  salts  of  lime  and  soda.  In  consumption,  bron- 
chitis, and  in  all  the  various  diseases  of  the  pulmonary  tract, 
experience  shows  this  preparation  to  be  of  great  use. 


J 


Partitrition,— Aletris  Cordial  (Rio), 
given  in  teaspoonful  doses  every  hour 
or  two  after  Parturition,  is  the  best 
agent  to  prevent  after-pains  and  hem- 
orrhage. By  its  direct  tonic  action  on 
the  uterus,  it  expels  blood  clots,  closes 
the  uterine  sinuses,  causes  the  womb 
to  contract,  and  prevents  subinvolu- 
tion. In  severe  cases,  it  can  be  com- 
bined with  ergot  in  the  proportion  of 
one  ounce  of  fluid  Ext.  Ergot  to  three 
ounces  Aletris  Cordial  (Rio).  It  is  the 
experience  of  eminent  practitioners,  in 
all  cases  where  ergot  is  indicated,  that 
its  action  is  rendered  much  more  effica- 
cious by  combining  it  with  Aletris  Cor- 
dial, Rio,  in  the  proportions  above 
stated, 

A  sample  bottle  will  be  sent  free  to  any  physician  who  desires  to 
test  it,  if  he  will  pay  the  express  charges. 

mo  CHEMICAL  CO.,  St.  Lottia,  Mo.,  U.  S.  A. 


ALWAYS  THE  SAME. 
A  STANDARD  OF  ANTISEPTIC  WORTH 


LISTERINE. 


LISTERINE  is  to  make  and  maintain  surgical  cleanliness  in  the   anti*J 

septic  and  prophylactic  treatment  and  care  of   all  parts  of  the  humair;; 

body. 
LISTERINE  i«  of  accnrately  determined  and  uniform  antiteptic  pow«rit 

and  of  positive  originality. 
LISTERINE  is  kept  in  stock  by  all  worthy  pharmacists  ererywfeerc. 
LISTERINE  is  taken  as  the  standard  of  antiseptic  preparations:      Th<| 

imitators  all  say,   *'It  is  something  like  Listerine." 


Ij-A  TVrREHT'S 

LiTHiATED  Hydrangea. 


A  valuabic  R»nal  Alteraiivf  and  AnH-Lithi< 
ttftnt  »f  msth44l  tervut  in  the  trtatment  0/ 
Cyttitis,  Gout,  Rhmmatism,  and  dise-tsts  of  the 
Uric  DUth4$is  itmtralhf. 


DUSCRIPTIVE  LITERATURE 

UPON  APPUCATION. 


LAMBERT  PHARMACAL  CO.,  St.  Louis, 


FEVER-KILLER--AN  ANODYNE— AN  ANTIPYRETIC 
:  "PYROCTIN."  Doctor  have  you  tried  it?  If  not,  send  your  address 
a  Postal  card  to  Murray  Drug  Co.,  Gen'l  Ag'ts,  Columbia,  S.  C,  they  will 
.dly  send  samples.    See  their  Ad'  in  this  Journal. 


enty-Flrst  Year.  APRIL   5,   1898.  Vol.  41.    NO.  7 , 

NORTH  CAROLINA 

MEDICAL  JOURNAL. 

PUBLISHED  SEMI-MONTHLY  AT  $2.00  PER  ANNUM. 

IRobert  D,  3ewett,  m,  H).  lebitor. 


[Entered  at  the  Post-OfEce  at  Winston,  N.  C,  as  Second-class  mail  matter. j 


Continue  to  ask  for  Parke,  Davis  &  Gd/s 
Anti-Diphtheritic  Serum.  We  contmue  to  lead 
in  potency,  efficiency  and  reliability  of  product. 
We  are  now  supplying  a  serum  testing 

t^  ^  r\  Antitoxic   units 
/  O  U  per  Cc. 

By  far  the  most  concentrated  Antitoxin  ever 
offered;  the  most  reliable.  Always  marketed 
in  hermetically  sealed  bulbs— not  ordinary  vials 
and  corks.   Latest  literature  mailed  upon  request. 

Parke,  Davis  &  Co., 

Home  0ffic«8  and  Laboratories.  Detroit,  MichiKan. 
Brandies  in  New  York,  Kansas  City.  Baltimora.  and  New  Orleans. 


Functional  Wrongs  of  Women.— P( 
the  functional  wrongs  of  women  Al 
TRis  Cordial  (Rio)  possesses  remark 
ble  curative  influence.  It  exerts  it 
special  tonic  action  action  on  the  who! 
uterine  system,  and  it  is  therefore  ind 
cated  in  all  abnormal  conditions  of  tl 
female  system,  without  regard  as  1 
whether  it  is  Dysmenorrhea,  Mono 
rh^gia,  Leucorrhea,  Amenorrhea, 
any  other  functional  wrong  peculiar 
the  female.  Women  suffering  from 
Aching  Back,  Bearing-Down  Abdo 
inal  Pains,  or  Soreness  in  the  Lumb 
Region,  should  be  given  ALETRK 
CORDIAL  in  teaspoonful  doses—fo 
or  five  times  a  day. 


1 


A  sample  bottle  will  be  sent  free  to  any  physician  who  desireSjt< 
test  it,  if  he  will  pay  the  express  charges. 

mo  CHEMICAL  CO.,  St.  Louis»  Mo.»  U.  S.  A. 


NORTH  CAROLINA 

MEDICAL  JOURNAL. 

A  SEIVJI-MONTHLY  JOURNAL  OF  MEDICINE  AND 
SURGERY. 

Vol.  XLI.  Winston,   April  5,    1898,  No.   7. 

©ricjinal  Conimuuicationa. 


TYPHOID    FEVER— AND  ITS  TREATMENT.* 
By  Thos.   M.    Riddick,   M.D.,  Woodville,  N.  C. 


THIS  paper  is  not  presented  in  any  didactic  spirit,  nor  witii 
any  idea  or  purpose  of  making  a  valuable  contribution 
to  the  history  of  therapeutic  science,  but  only  in  the 
hope  that  the  discussion  of  the  subject,  which  it  may  provoke, 
will  elicit  the  practical  views  and  opinions  of  gentlemen  who 
have  battled  successfully  with  this  ofttimes  fatal  malady.  While 
there  are  few  doctors  who  question  the  existence  of  enteric 
fever  in  the  tidewater  section,  there  are,  on  the  other  hand, 
many  practical  and  learned  physicians  who  have  seen  and 
treated  typical  cases  of  genuine  typhoid  fever  in  the  same  re- 
gion, and  the  testimony  which  they  furnish  can  not  be  received 
with  incredulity  or  treated  with  indifference.  Although  malaria 
is  the  kindly  screen  behind  which  are  hid  many  diagnostic  sins, 
the  clinical  picture  presented  by  an  established  case  of  enteric 
fever  is  so  radically  different  from  any  febrile  affection  caused 
by  malarial  infection  that  it  is  not  easy  to  confound  the  two 
affections  in  diagnosis.  The  quinine  test  too,  when  fully  and 
liberally  made,  eliminates  every  feature  of  doubt,  for  remittent 
fever  will  yield  as  readily  to  cinchona,  as  intestinal  colic  will  to 
cathartics,  opium  and  hot  water. 
*Read  before  the  Tidewater  Medical  Association,  January  20,  1898. 


2IO  RIBDlCK-TVPIIOro  P^EVER-AND  ITS  TliEATMENT. 

I  shall  omit  any  descriptive  reference  to  the  causation  and 
pathology  of  this  disease  for  I  take  it  that  you  are  all  more  than 
familiar  with  those  features.  The  treatment  of  the  trouble  and 
its  complications  only  will  be  considered. 

In  the  very  outset  I  want  to  say  that  I  have  never  given  any 
faith  to  the  socalled  abortive  treatment  of  typhoid  fever.  As 
Dr.  Austin  Flint  says,  "it  is  essentially  a  self  limited  disease 
and  runs  its  course,  and  while  the  severity  of  an  attack  may  be 
mitigated,  in  a  measure,  by  proper  and  judicious  palliative 
measures,  the  morbific  factors  at  work  can  not  be  jugulated,  by 
any  species  of  therapeutic  interference. "  Or  I  take  it,  a  phy- 
sician can  no  more  suppress  or  abort  an  attack  of  enteric  fever, 
when  once  developed,  than  an  experienced  mariner  can  quell 
the  howling  of  the  elements  by  commanding,  "Peace  be  still!" 
The  doctor  can  only  guide  and  pilot  his  patient  through  the 
dread  seizure,  just  as  the  nautical  man  brings  his  ship  into  port 
over  tossing  and  billowy  waters. 

Of  course  in  expressing  that  opinion,  so  dogmatically,  I  mean 
no  uiijust  criticism  of  these  gentlemen  who  hold  to  the  views  of 
Dr.  Woodbridge,  for  evidently  they  are  as  honest  in  their  own 
convictions  as  I  am  in  mine. 

The  cardinal  points  on  the  treatment  of  typhoid  fever  are  to 
control  undue  pyrexia;  to  keep  the  emunctories  active,  so  as  to 
expedite  the  elimination  of  toxins  from  the  system,  and  limit 
their  absorption ;  to  support  the  enfeebled  and  flagging  heart, 
so  as  to  maintain  throughout  the  system  a  uniform  circulatavy, 
activity  and  prevent  local  engorgement  and  congestion  ;  to  heal 
the  lesions  in  the  peyerian  glands;  to  tranquilize  the  nervous 
system  and  maintain  its  tone  as  far  as  in  our  power  lies;  and  to 
generously  nourish  the  patient,  so  as  to  check  the  waste  of  time, 
support  the  strength,  and  inhibit  the  progress  of  degenerative 
processes. 

Now  what  are  the  means  and  measures  by  which  these  desir- 
able results  can  be  best  accomplished? 

For  the  reduction  of  temperature  undoubtedly  there  is  no 
system  of  treatment  superior  to  the  cold  water  immersion  of 
Brand,  but  that  is  not  always  available  to  country  practitioners 
who  lack  the  facilities  and  mechanical  appliances  which  are 
always  accessable  in  hospital  practice.  In  many  localities  too, 
the  laity  have  not  been  educated  up  to  the  point  of  only  addra- 


RIDDICK-TYPIIOID  FEVER— AND  ITS  TREATMENT.  2  1  I 

dating  that  antithermic  measure,  and  the  medical  man  who 
might  have  the  misfortune  to  lose  a  patient  who  had  been  sub- 
jected to  the  plunging  process  would  not  only  be  regarded  as  a 
bold  and  daring  innovator,  but  the  most  severe  and  unjust 
proscription  would  be  visited  upon  him  by  many  who  did  not 
endorse  his  practice.  Indeed,  he  might  even  be  threatened 
with  the  inquisition  of  a  grand  jury,  and  have  a  narrow  escape 
from  the  toils  of  the  law. 

My  method  has  been  to  compromise  upon  the  application  of 
cold  to  the  head,  and  in  grave  cases,  to  the  bowels  also.  The 
cold  pack  is  also  used,  if  the  hyperpyrexia  demands  it.  At  the 
same  time  I  give,  during  the  afternoon  hours,  when  the  tem- 
perature elevation  is  greatest,  small  doses  of  acetanilide,  every 
three  or  four  hours.  That  generally  suffices,  in  most  cases,  to 
keep  the  fever  under  103,  and  it  is  only  the  continued  excessive 
temperature  that  superinduces  degeneration  of  the  cardiac 
muscular  tissue,  and  begets  marked  excitability  and  prostration 
of  the  nervous  system. 

Perhaps  there  are  no  features  of  more  importance  in  the  man- 
agement of  typhoid  patients  than  the  free  and  prompt  action  of 
the  kidneys,  and  the  proper  regulation  of  the  bowels,  for  it  is 
chiefly  through  these  routes  that  the  death  dealing  poisons  make 
their  exit  from  the  system.  To  secure  good  nephritic  activity 
there  is  nothing  better  than  the  Buffalo  Lithia  Water — though 
that  is  not  always  available.  In  the  absence  of  it  I  substitute 
the  mixture  of  potassium  acetate  and  spirits  nitre,  with  lithia 
tablets.  In  the  second  week,  when  the  cardiac  energy  begins 
to  wane,I  give  tinct.  digitalis  and  strychniasulphate,  to  buttress 
the  flagging  heart.  Water  too,  the  best  of  diuretics,  is  given 
in  generous  draughts,  ad  libitum^  for  thorough  internal  irriga- 
tion is  altogether  desirable  in  this  affection,  to  flush  out  the 
system,  so  to  speak.  The  water  should  be  boiled,  filtered,  and 
afterwards  cooled,  so  as  to  render  it  palatable  to  the  patient. 

Calomel  I  regard  as  a  drug  of  great  potency  in  typhoid  treat- 
ment, and  frequently  give  it  in  eight  or  ten  grain  doses,  twice, 
and  even  three  times,  during  an  attack,  always  subdividing  the 
quantity  in  its  administration  and  following  with  a  saline 
draught.  It  not  only  sweeps  out  the  intestinal  tube,  and  keeps 
the  secretions  active  and  free,  but  also  exercises  a  germicidal  effect 


212  RIDDICK— TYPHOfD  FEVER-AND  ITS  TREATMENT. 

upon  the  bacilli.  It  is  always  my  initial  dose  in  assuming  charge 
of  a  typhoid  case. 

Should  constipation  be  present  at  any  time,  together  with 
pronounced  tympanites,  an  enema  of  warm  water,  glycerine, 
and  spirits  turpentine  is  given  to  open  bowels,  and  turpentine 
stupes  are  applied  over  bowels.  While  it  is  always  my  aim  to 
keep  the  bowels  open  and  free,  anything  like  hypercatharsis 
should  always  be  controlled,  because  of  the  increased  debility 
which  it  produces.  Bismuth  salicylate,  or  sub-nitrate,  are  my 
choice  of  astringents,  unless  hemorrhage  should  occur,  when 
the  lead  and  opium  pill  is  substituted,  an  ice  bag  applied  over 
bowels,  and  ergotine  is  given  by  hypodermic  injection. 

Many  and  various  remedies  have  strong  advocates  as  intestinal 
antiseptics  and  perhaps  there  are  none  of  them  devoid  of  merit. 
Guaiacol  carbonate,  salol,  creosote,  beta  napthol,  all  find  favor 
with  their  respective  friends.  But  to  me  there  is  no  one  pre- 
ferable to  that  venerable  old  time  favorite,  turpentine,  first  in- 
troduced to  the  profession  as  a  healing  agent  in  typhoid  fever, 
by  the  eminent  and  practical  Dr.  Geo.  B.  Wood,  of  Philadel- 
phia. To  an  adult  I  adminster  gtts.vj  ,  in  half  a  tumbler  of 
milk  and  lime  water  every  two  hours — and  to  that  is  added,  as 
an  antiseptic  nutrient  a  tablespoonful  of  liquid  peptonoids,  with 
creosote.  If  asthenia  be  marked,  good  brandy  or  whiskey  are 
given  as  occasion  may  require.  As  an  auxiliary  intestinal  an- 
tiseptic, I  know  of  nothing  better  than  the  carbolic  acid  and 
iodine  mixture — given  three  times  a  day. 

While  turpentine  meets  many  requirements  in  typhoid  cases 
as  an  antiseptic,  diuretic,  haemostatic,  and  diffusable  stimulant, 
I  have  seen  cases  where  it  produced  such  renal  irritation  as  to 
contraindicate  its  use.  At  other  times,  there  is  great  gastric 
intolerance.  In  that  event  my  reliance,  as  an  intestinal  healer, 
is  upon  silver  nitrate,  so  highly  commended  by  Dr.  Pepper. 

The  coexistence  of  pneumonia,  pleurisy  or  bronchitis,  must 
be  controlled  by  such  therapeutic  means  as  will  suggest  them- 
selves to  every  prudent  and  judicious  doctor. 

When  meningeal  inflammation  supervenes  I  never  fail  to  shave 
the  head  and  blister.  This  is  followed  by  the  ice  cap  to  head. 
The  nervous  excitement  is  controlled  by  codeine  and  sodium 
bromide.      Sleep  is  secured  by  trional  if  needful. 


VON  HOFMAN— PELVIC   INFLAMMATION.  2  I  3 

I  take  it  that  it  is  wholly  needless  to  advert  to  the  necessity 
of  perfect  rest  and  quietede  for  patient — the  use  of  the  bed-pan, 
a  thoroughly  liquid  diet,  for  at  least  two  weeks  after  convales- 
cence, and  the  thorough  disinfection  and  removal  to  a  distant 
point,  of  all  excreta  of  patient.  The  thorough  disinfection  of 
the  sick  room  with  Piatt's  chlorides  or  other  disinfectant  is  in- 
dispensable, and  in  no  case  are  the  hygenic  advantages  of 
thorough  cleanliness  more  apparent  than  in  typhoid  fever. 
After  the  cessation  of  fever,  and  convalescence  is  progressing, 
it  is  often  my  custom  to  prescribe  the  elixir  phosphate  iron, 
quinine  and  strychnine — together  with  Fairchilds'  essence  pep- 
sine.  This  not  only  aids  the  frequent  faulty  digestion,  but  also 
exercises  its  tonic  and  roborant  action  upon  the  system  and 
hastens  the  restoration  of  the  patient  to  his  former  condition  of 
health  and  vigor. 


Clinical  Xectures. 


PELVIC  INFLAMMATION.* 

A.    Von  Hofman,  M.D.,   Professor  of  Gynecology,  Medical 
Department,  University  of  California. 


GENTLEMEN:  We  had  last  time  three  cases;  the  examin- 
ation showed  that  in  the  first  case  there  was  a  mass  in 
the  pelvis  on  the  left  side  of  the  uterus,  pushing  the  uterus 
to  the  right  side:  this  mass  was  not  circumscribed,  not  a  round 
mass;  it  filled  out  the  left  side  of  the  pelvis,  between  the  uterus 
and  the  bones.  It  extended  posteriorly  about  half  way  to  the 
median  line  of  the  uterus,  but  was  not  felt  in  the  Douglas  pouch, 
and  extended  upwards  to  about  the  line  corresponding  to  the 
fundus  of  the  uterus,  below  and  downwards  to  the  junction  of 
the  vagina  and  the  uterus.      It  did  not  offer  any  fluctuation. 

Second  and  third  cases:     The  two  other  cases  showed  masses 
behind  the   uterus    pushing  the    uterus  upward     and   forward. 
*Delivered  at  City  and  County  Hospital,  January  1898. 


2  14  ^'**^'^'   llOiAIAN-PELVIC   INFLAMMATION. 

These  masses  could  be  felt  above  the  cervix  in  the  Douglas  pouch,. 
extending  to  both  sides  of  the  pelvis,  but  did  not  reach  as  far 
down  on  the  side  as  the  mass  in  the  first  case.  The  masses  in 
the  second  and  third  cases  could  be  felt  more  as  round  circum- 
scribed masses. 

The  diagnosis  in  all  the  three  cases  was  pelvic  inflammation. 
These. three  cases  did  not  give  the  same  results  upon  examination, 
but  the  diagnosis  in  all  three  cases  was  the  same;  different  con- 
ditions may  exist  in  this  disease  of  pelvic  inflammation,  and  tO' 
understand  these  conditions  it  is  best  to  divide  the  different  cases. 
In  non-infective  cases  the  disease  may  remain  localized  at  the 
spot  where  the  inflammation  first  commenced,  and  not  attack  any 
of  the  neighboring  organs,  or  infect  the  whole  system.  In 
infective  cases  the  whole  system  would  be  infected  and  the  in- 
flammation would  spread  from  the  point  of  entrance  of  infection 
to  the  neighboring  organs,  and  may  spread  into  the  peritoneum, 
and  general  peritonitis  may  result. 

The  seat  of  the  inflammation  may  be  different;  it  may  be  in 
t-ie  connective  tissue  of  the  pelvis  or  in  the  peritoneum.  In  the 
first  case  the  connective  tissue  was  affected.  In  those  cases  in 
which  the  peritoneum  is  the  seat  of  inflammation  I  would  expect 
also  parametitis,  as  both  of  these  forms  are  common  at  the  same 
time.  But  in  the  first  case  the  seat  of  the  iaflammation  was  the 
connective  tissue  of  the  broad  ligament,  and  in  the  two  other 
cases  the  seat  of  inflammation  was  in  the  peritonenm,  involving 
at  the  same  time  the  tubes  and  ovaries,  so  that  the  two  forms 
can  be  easily  shown  in  these  cases.  In  the  first  case  we  found 
parametritis,  in  the  two  other  cases  perimetritis. 

As  the  broad  ligament  consists  of  only  very  little  connective 
tissue  covered  by  the  peritoneum,  it  is  natural  that  both  parts  be 
generally  affected  together.  The  seat  of  the  tumor  often  enables 
us  to  make  the  diagnosis  between  these  two  conditions,  parame- 
tritis and  perimetritis.  Non-infective  perimetritis  is  often  over- 
looked in  the  acute  stage  and  we  find  only  the  results  ;the  results  of 
non-infective  perimetritis  would  be  adhesions  between  the  uterus 
and  the  rectum,  ovaries  and  tubes,  and  ovaries  and  uterus,  ovaries 
and  rectum.  The  results  of  non-infective  parametritis  would  be 
cicatricial  tissue  in  the  broad  ligament,  as  we  see  after  laceration 
of  the  cervix,  which  extends  into  the  broad  ligament ;  the  patient 


TON  nOFMAN— PELVIC  INFLAMMATION.  215 

after  the  confinement  during  which  such  tear  occurs,  does  not 
show  any  symptoms  of  fever.  The  injury  in  the  broad  ligament 
will  heal;  but  afterwards  the  result  of  the  non-infective  perame- 
tritis  can  be  felt  as  a  hard,  dense  band  'n  the  broad  ligament, 
pulling  the  cervix  over  to  this  side. 

The  infective  forms  of  the  disease  are  of  greater  importance. 
We  take  up  first  infective  perimetritis.  We  can  distinguish  two 
different  forms:  the  septic  and  the  gonorrhceal.  In  septic  acute 
perimetritis  the  infection  takes  place  in  the  uterus  in  some  cases 
and  travels  upwards  into  the  peritoneum  through  the  Fallopian 
tubes,  or  it  travels  from  any  infected  place  in  the  cervix  through 
the  lymphatic  vessels  and  so  reaches  the  ovaries  and  theperiton- 
cum.  The  disease  shows  in  the  beginning  all  the  synptoms  of 
acute  inflammation  of  the  peritoneum  and  very  soon  an  exudation 
takes  place,  the  liquid  exudate  sinks  down  into  the  Douglas  sac, 
the  deepest  part  of  the  peritoneal  cavity;  this  purulent  exudate 
will  remain  for  some  time,  and  the  peritoneum  forms  adhesions 
above  it,  so  that  the  general  peritoneal  cavity  is  protected  against 
further  infection.  The  purulent  effusion  can  change  so  that  the 
liquid  parts  of  the  pus  are  absorbed  and  the  thick  pus  remains. 
Abscess  is  formed  in  this  way ;  these  abscesses  can  break  through 
into  the  vagina  or  rectum  or  bladder,  and  under  somecircumstan- 
ces  into  the  peritoneal  cavity.  After  the  abscess  breaks  and  the 
pus  comes  away,  the  walls  of  the  abscess  may  tall  together  and 
heal. 

When  the  abscess  breaks  into  the  rectum,  fecal  matter  may 
get  into  the  abscess  cavity  and  the  abscess  continue  to  discharge 
and  will  not  heal  without  surgical  assistance.  As  soon  as  this 
exudation  takes  place,  the  patient  offers  symptoms  of  pain  in  the 
pelvis,  high  fever,  often  beginning  with  achill ;  will  have  pain  on 
micturition,  pain  on  defecation,  and  will  complain  of  pain  in  the 
lower  abdomen.  This  pain  extends  to  the  back  and  often  down 
the  thighes.  The  patienc  should  be  kept  in  bed,  on  the  back,  per- 
fectly quiet  and  with  a  frame  to  support  the  bedding  to  relieve 
the  pressure  upon  the  abdomen.  The  irritation  of  the  peritoneum 
will  give  symptoms  of  nausea  and  very  often  vomiting.  On 
examination  we  find  that  the  pelvis  is  filled  up  with  a  mass, 
especialy  behind  the  cervix  in  the  Dougl-as,  extending  to  either 
or  both  sides,  or    at  least  to  one  of    the  sides   more  than    to  the 


2  I  6  VON  HOFMAN-PELVIC  INFLAMMATION. 

Other,  i  nd  which  fixes  at  the  same  time  all  the  organs  of  the 
pelvis.  This  is  one  of  the  characteristic  signs  of  pelvic-inflamma- 
tion— the  organs,  especialy  the  uterus,  are  fix^ed  and  immovable. 

We  cannot  make  out  in  these  cases  the  ovaries  and  Fallopian 
tubes;  they  are  contained  in  tlie  mass  of  adhesions;  they  are 
always  inflamed  by  it,  and  infected  by  the  septic  poison.  The 
diagnosis  of  the  condition  is  made  by  the  examination  from  the 
characteristic  signs,  the  seat  of  the  tumor  behind  the  cervix,  the 
pain  on  pressure,  the  fixation  of  the  organs  and  the  high  tem- 
perature. Later  on  the  diagnosis  of  the  abscess  is  made  by  the 
signs  of  localized  softening,    or  by  the  feeling  of  fluctuation. 

The  prognosis  is  grave;  if  the  abscess  breaks  and  heals,  the 
patient  may  be  an  invalid  for  a  long  time.  The  danger  is  present 
as  long  as  the  acute  symptoms  of  general  infection  last ;  but  after 
the  abscess  breaks  and  the  pus  is  removed,  there  is  a  possibility 
of  all  the  organs  becoming  normal  again,  especially  in  cases  of 
septic  infection.  In  gonorrhoeal  infection  we  see  the  same 
symptoms,  only  the  history  is  different  in  the  beginning.  The 
patient  will  offer  first  the  symptoms  of  acute  gonorrhoea:  before 
the  infection  travels  through  the  uterus  into  the  Fallopian  tubes 
and  fixes  the  tube  and  ovaries  and  then  into  the  peritoneum,  so 
that  we  are  able  to  make  a  diagnosis. 

The  diagnosis  is  made  before  the  peritoneum  is  affected.  Very 
soon  effusion  or  an  exudation  will  take  place,  and  then  we  have 
the  same  symptoms  as  the  septic  infection. 

Treatment  \n  the  acute  cases  should  be  perfect  rest,  which  we 
can  obtain  by  keeping  the  patient  in  bed,  giving  her  opium  or 
morphine,  and  a  good  plan  is  to  combine  opium  with  quinine.  If 
you  find  in  the  beginning  of  the  case  that  the  rectum  is  full,  the 
rectum  should  be  emptied  by  injection  and  then  left  alone  for 
several  days;  after  five  days  you  may  begin  to  give  calomel  in 
small  doses,  one  grain  every  hour,  until  the  bowels  move.  Out- 
side applications  can  be  made  of  flax-seed  poultices  of  curpentine 
stupes.  Diet  should  be  liquid  food,  milk,  beef-tea  gruel  and 
barley  water.  If  the  cases  have  passed  the  acute  stage  and  the 
sensibility  is  less,  and  the  patient  able  to  be  moved,  then  hot 
baths,  glycerine  tampons  or  suppositories  during  the  night  will  be 
found  of  great  benefit.  If  the  exudation  has  disappeared  or  is 
absorbed,  we  find  the  adhesions  and  we  must  try  to  lessen  them 


VON  IIOFMAN-PEI.YIC  INFLAMMATION.  217 

and  to  bring  the  uterus  into  condition  so  that  it  is  movable  again. 
To  lessen  these  adhesions  we  can  try  rectal  injections,  for  which 
we  use  a  great  quantity  of  warm  water  or  sweet  oil,  hip  baths, 
wet  applications  and  vaginal  douches,  tampons  with  ichthyol 
and  iodine  and  painting  the  roof  of  the  vagina  and  cervix  witli 
iodine.  This  treatment  must  be  continued  for  several  months 
before  any  results  are  to  be  expected.  The  adhesions  can  be 
broken  down  by  force,  but  this  should  be  only  when  the  patient 
is  under  ether.  Massage  can  be  of  benefit ;  the  use  of  the  sound 
will  bring  up  the  uterus  until  it  finally  can  be  replaced  and 
brought  into  normal  position;  as  soon  as  the  fluctuation  is  felt 
the  abscess  should  be  opened,  washed  out  and  drained,  and 
cleaned  every  day  until  the  walls  fall  together  and  the  abscess 
heals. 

If  the  patient  continues  to  complain  and  cannot  be  made  cora- 
fortable,  the  adhesions  can  be  broken  down.  The  question  rises 
if  it  would  not  be  better  to  remove  the  ovaries  and  the  tubes  at 
the  same  time.  To  establish  good  drainage,  the  removal  of  the 
uterus  has  been  recommended. 

Septic paremetritis  is  seen  generaly  after  confinements  or  after 
operations;  the  irfliammation  is  found  here  especially  in  the 
connective  tissue  of  the  ligaments ;  you  notice  the  signs  of  inflam- 
mation, swelling,  congestion,  and  exudation  into  the  tissue  by 
which  the  small  blood  vessels  are  compressed:  stasis  of  the 
blood  vessels  takes  place  in  cases  where  the  tissue  suppurates. 
The  process  may  be  arrested  at  any  time  before  suppuration 
takes  place,  then  the  thickening  of  the  broad  ligament  results. 
If  suppuration  takes  place  the  pus  can  find  its  way  along  the 
iliac  fascia,  and  can  reach  the  anterior  abdominal  wall  by  fol- 
lowing the  connective  tissue.  The  abscess  may  break  above 
Poupart's  ligament,  into  the  vagina,  rectum  or  bladder. 

The  diagnosis  can  be  made  if  we  find  the  organs  of  the  pelvis 
fixed,  the  mass  pushing  the  uterus  over  to  either  side,  high  fever 
and  sensitiveness.  The  diagnosis  between  peri  and  parametrits 
can  be  made  by  the  seat  of  the  tumor;  the  symptoms  are  the 
same  as  in  perimetritis  and  the  treatment  is  the  same  also. 

This  form  of  pelvic  inflammation  can  be  prevented  by  cleanli- 
ness during  operations  and  during  confinements  ;  in  acute  stages 
the  patient    is   to   be  kept    in  bed  perfectly    quiet;    opium    and 


2  I  8  VON  IIOFilAN— PELVIC  INFLAMMATION. 

quinine  may  be  given,  hot  vaginal  douches  and  flax-seed  poultices- 
are  used;  later,  hot  applications  or  blisters  may  be  applied.  If 
there  is  no  suppuration  ,  massage  will  be  of  benefit ;  if  it  comes  to- 
an  abscess,  fluctuation  can  usually  be  felt  generally  at  the  lowest 
point  of  the  mass  in  the  roof  of  the  vagina ;  if  the  abscess  is  to  be 
opened,  washout,  drain,  and  clean  it.  In  the  last  few  years  the 
pelvic  suppurations  have  been  treated  by  the  removal  of  the 
uterus  from  below,  or  by  removal  of  the  ovaries  and  tubes  and 
opening  the  abscess  from  above.  In  France  especially,  it  has 
been  recommended  to  remove  the  uterus  in  any  case  of  pelvic 
suppuration  to  establish  free  drainage ;  and  even  in  cases  in  which 
several  smaller  abscesses  are  present  it  is  claimed  that  the  re- 
moval of  the  uterus  is  sufficient  in  order  to  get  these  patients 
well,  even  if  all  the  different  abscesses  be  not  opened.  Other 
physicians  are  against  treating  pelvic  suppurations  from  below, 
and  want  to  treat  all  the  cases  by  abdominal  incision,  opening 
and  draining  the  abscess  througli  such  incisions.  I  do  not  think 
that  all  cases  can  be  treated  alike. 

In  my  opinion  the  best  way  of  treating  pelvic  suppurations  is, 
if  you  can  fee)  the  fluctuation  from  below,  to  open  the  abscess 
and  to  drain.  If  no  suppuration  can  be  felt,  especially  if  the 
ovaries  and  Fallopian  tubes  are  affected,  I  would  consider  it 
better  to  open  the  abdomen  above,  remove  the  diseased  organs, 
and  drain  if  necessary.  I  considei  it  too  dangerous  to  work 
among  adhesions  from  below;  you  cannot  see;  you  have  to  feel. 
Many  cases  are  reported  in  which  the  rectum  has  been  opened  by 
the  physician,  who  thought  that  he  was  opening  a  pyosalpinx; 
this  opening  of  the  rectum  generally  heals  without  any  further 
trouble,  but  it  shov/s  that  the  physician  cannot  be  absolutely 
sure  of  what  he  is  doing  v.hen  he  is  at  work  with  his  fingers  in 
the  dark.  If  he  can  see  the  organs  as  we  do  after  the  abdominal 
incision  he  can  remove  them  without  injuring  the  neighboring  • 
organs,  which  of  course  wculd  be  much  safer  for  the  patient. 

It  has  been  recommended  during  the  last  few  years  to  treat 
pelvic  inflammation  fi'om  the  beginning  by  an  incision  into  the 
diseased  tissues  before  the  pus  has  appeared;  as  the  recovery  of 
the  patient  after  this  procedure  is  no  quicker  than  by  using  the 
old-fashioned  treatment,  I  do  not  recommend  this  method.  I 
am  not  very  much  in  favor  of  removing  the  uterus  in  pelvic  sup- 


SOCIETY  REPORTS. 

219 

purations.  I  believe  we  can  remove  the  pus  by  opening  the 
abscess;  the  uterus  will  be  healthy  afterwards;  and  an  organ 
should  not  be  removed  which  can  be  kept  without  injury  to  the 
patient.  In  septic  cases  we  often  see  that  organs  arc  perfectly 
normal  afterwards.      This  is  shown  by  subsequent  confinements, 

which  of  course  cannot   occur  when    Ihe   uterus  is   removed. 

Pacific  Record  of  Medicine  and  Surgery. 


Society  1?eport6. 


SECTION  ON  ORTHOPEDIC  SURGERY  BEFORE  THE 
NEW  YORK  ACADEMY  OF  MEDICINE. 

Meeting  of  February  17,  1898.      Dr.  E.  G.  Janeway,   President 
of  the  Academy  in  the  Chair. 


Dr.  T.  H.  Myers  read  a  paper  on  "Non-Tubercular  Inflam- 
mations of  the  Spine."  The  following  is  an  abstract  of  the 
paper  and  discussion: 

Dr.  Myers  said  that  syphilitic  inflammation  of  the  spine  was 
found  in  all  regions  of  the  column  and  might  involve  any  of 
the  tissues  and  any  of  the  vetrebral  parts,  with  the  exhibition 
of  periostitic,  osteitic  and  other  varieties  of  inflammation.  In 
the  cases  of  two  boys  whose  histories  were  related,  the  cervical 
and  dorsal  regions  were  affected  respectively.  In  the  former 
there  was  the  deformity  of  wry-neck  and  in  the  latterakyphos  is. 
Pain  and  rigidity  were  present.  There  was  no  history  of  trans- 
mission but  the  presence  of  syphilitic  dactylitis  and  prompt  and 
repeated  response  to  anti-syphilitic  medication  determined  the 
diagnoses.  Both  patients  were  much  relieved  by  mechanical 
treatment. 

Dr.  W.  R.  Townsend  said  that  this  form  of  spine  disease  was 
a  rare  affection.  The  kyphosis  did  not  differ  from  that  of  the 
spine  affected  with  tuberculosis  and  there  was  generally  a  his- 
tory of  inherited  syphilis. 


220  SOCIETY  KEPORTS. 

Dr.  R.  H.  Sayre  said  that  in  making  a  aiagnosis  in  children 
the  presence  of  multiple  arthritis  would  indicate  syphilitic 
rather  than  tubercular  disease  of  the  spine,  especially  if  the 
child  were  under  i8  months  of  age. 

Dr.  B.  Lapowski  said  that  dactylitis  syphilitic  had  no  charac- 
teristic symptoms  and  was  therefore  valueless  in  distinguishing 
between  syphilis  and  tuberculosis.  Neither  was  a  response  to 
anti-syphilitic  treatment  a  certain  guide  since  anti-syphilitic 
medication  produced  good  results  in  tubercular  diseases  and  of 
late  hypodermic  injections  of  sublimate  had  been  used  with 
good  effect  in  gonorrhoeal  rheumatism. 

The  President  said  that  it  was  not  rare  to  see  a  person  suffer- 
ing from  both  tuberculosis  and  syphilis.  He  had  also  seen 
cases  which  were  thought  to  be  tubercular  but  which  yielded  to 
anti  syphilitic  treatment. 

Dr.  Myers  said  that  the  relation  of  congenital  syphilis  to 
tuberculosis  was  not  well  understood.  It  was  possible  that 
transmission  might  make  the  offspring  a  more  than  usually 
favorable  soil  for  tubercular  infection.  Moreover,  there  were 
cases  of  a  mixed  infection,  a  tuberculous  subject  acquiring 
syphilis  or  vice  versa. 

Rheuviatic  Inflammation  of  the  Spine  was  more  certainly  recog- 
nized. In  rheumatoid  arthritis,  which  was  by  far  the  most  com- 
mon, other  joints  were  also  affected  and  there  was  slowly  in- 
creasing and  poorly  defined  deformity  from  inability  of  the 
column  to  withstand  the  superimposed  weight,  with  a  varying 
degree  of  pain.  Mobility  and  pain  declined  together  and  the 
latter  ceased  when  anchylosis  was  established.  The  bones  ex- 
hibited sclerosis  with  atrophy  and  absorption  under  pressure. 
Active  medication  was  required  with  protection  and  immobili- 
zation. Every  effort  should  be  made  to  secure  anchylosis,  if  it 
was  inevitable,  in  the  best  possible  position  of  the  spine. 

Dr.  C.  C.  Ransom  would  make  a  clear  distinction  between 
spinal  rheumatoid  arthritis  and  rheumatic  disease  of  the  <^pine. 
The  latter  affection,  when  limited  to  the  spine,  was  compara- 
tively rare  and  usually  affected  the  lower  dorsal  and  upper  cer- 
vical regions,  rarely  exhibiting  cartilaginous  and  osseous  changes 
only  in  very  exceptional  patients  and  in  those  of  advanced  years. 
Rheumatoid  arthritis  of  the  spine,  on  the  other  hand,  exhibited 


SOCIKTY  REPORTS.  22  1 

muscular  atrophy,  deposits  about  the  joints  and  characteristic 
deformities  of  other  affected  joints.  In  its  treatment  the  classic 
remedie  sused  in  rheumatism  had  little  if  any  effect  and,  with 
the  exception  of  iodide  of  potassium,  were  apt  to  do  more  harm 
than  good.  In  the  treatment  of  rheumatism  of  the  spine,  how- 
ever, the  methods  usually  employed  in  rheumatism  would  be 
found  to  give  good  results.  Specific  remedies,  such  as  salicylic 
compounds,  iodide  of  potassium  and  colchicum  might  be  used 
in  the  active  stage  and  to  relieve  distressing  symptoms.  But  to 
cure  the  trouble  our  dependence  must  be  on  general  tonic  and 
hygienic  treatment  includmg  iron,  arsenic,  the  hypophosphites, 
hydrotherapy,  massage  and,  when  pain  on  motion  had  suffi- 
ciently subsided,  proper  forms  of  active  exercise  regularly  car- 
ried out. 

Dr.  Townsend  cQxAd.  recall  but  one  or  two  cases  in  which  the 
diagnosis  of  rheumatic  afiection  of  the  spine  could  be  clearly 
made  out.  He  referred  to  rheumatic  changes  in  the  bones  and 
joints  of  the  spine.  Rheumatic  pains  affecting  the  spinal  mus- 
cles were  sufficiently  common. 

Dr.  Sayre  recalled  a  case  which  at  first  seemed  to  be  tuber- 
cular inflammation  of  the  cervical  spine.  There  were  pain  and 
limited  motion.  A  support  enabled  the  patient  to  move  with- 
out pain.  Different  diagnoses  were  made  by  a  number  of  ob- 
servers. Syphilis  was  eliminated.  Atrophy  and  an  inelastic 
condition  of  the  muscles  suggested  a  nervous  origin  of  the 
trouble.  The  inflammation  progressed  and  a  few  yeais  later 
the  entile  spine  was  rigid.  Stiffness  of  the  costo-sternal  and 
costo  vertebral  joints  interfered  with  full  respiration  and  other 
joints  were  involved.  There  had  been  some  relief  from  gentle 
massage. 

Dr.  Myers  said  that  the  diagnosis  of  malignant  disease  of  the 
spine  was  readily  made  in  cases  in  which  a  malignant  growth 
had  already  occurred  in  another  part  of  the  body,  but  if  the 
primary  manifestation  was  in  the  spine  the  affection  might  be 
overlooked.  The  growth  might  infiltrate  the  bodies,  transverse 
processes,  laminae  and  spines  or  occur  c;xternally  on  the  sides 
of  the  vertebrae.  Small  metastases  might  occur  in  the  neigh- 
borhood and  the  spinal  nerves  were  oppressed  by  invasion  of 
the  inter-vertebral  foramina.      The  average  duration  of  life  after 


2  22  SOCIETY  REPORTS. 

the  onset  was  eight  months.  The  most  constant  symptoms  were 
pain  and  motor  paralysis.  Kyphosis  was  found  in  some  cases. 
Severe  pain  and  the  occurrence  of  sensory  paralysis  before  the 
appearance  of  the  motor  symptoms  were  considered  as  rather 
diagnostic. 

Dr.  V.  P.  Gibney  said  that  this  affection  was  very  interesting 
to  the  general  practitioner  and  to  the  specialist  because  of  the 
peculiar  symptoms  and  the  difficulty  of  making  the  diagnosis, 
Vv-hich,  however,  could  as  a  rule  be  made  early.  The  severity 
of  the  symptoms  was  so  great  and  the  pain  in  certain  regions 
was  so  acute  and  persistent  that  their  significance  could  gener- 
ally be  recognized.  Another  point  was  the  cicatrix  in  the 
mammary  region  showing  a  previous  amputation  of  the  breast, 
a  fact  which  was  often  concealed  by  the  patient.  If  this  was 
found,  the  disease  of  the  spine  was  undoubtedly  malignant. 

Dr.  B.  Curtis  had  operated  in  a  case  in  which  the  diagnosis 
was  uncertain.  The  patient  was  a  woman  of  35  j'^ears.  The 
right  breast  had  been  amputated  a  year  previously  for  a  sup- 
posed malignant  growth.  She  had  complained  for  five  months 
of  pain,  not  very  severe  in  the  back  and  chest.  Examination 
showed  practicall)''  nothing.  Later  the  knee  reflex  was  lost  and 
very  soon  anaesthesia  appeared.  The  prick  of  a  pin  was  not 
felt  below  the  level  of  the  umbilicus.  There  were  retention  of 
urine,  involuntary  discharge  of  faeces,  complete  paralysis  of 
the  lower  extremities  and  kyphosis  in  the  mid-dorsal  region. 
A  bed-sore  developed  over  the  sacrum.  The  patient  was  exam- 
ined by  a  number  of  men  whose  diagnoses  varied  from  secon- 
dary deposit  to  Potts'  disease.  Operation  was  urged  and  rather 
against  his  own  judgment,  as  he  favored  the  former  opinion,  he 
was  induced  to  do  a  laminectomy  on  the  5th,  6th  and  7th  dor- 
sal vertebrae.  He  found  the  cord  slightly  compressed  and  con- 
gested. The  0th  dorsal  was  softened  and  proiected  somewhat 
against  the  anterior  surface  of  the  cord.  There  was,  however, 
no  marked  thinning  of  the  cord  and  nothing  in  the  cord  to  ac- 
count for  the  severity  of  the  symptoms,  which  were  not  relieved. 
The  wound  healed  by  primary  union  but  the  bed  sore  was  very 
extensive  and  the  sacrum  necrotic.  The  patient  died  of  sepsis 
on  the  i6th  daj?-  after  the  operation. 

Dr.  C.  N'.  Z><?7£v/ referred  to  the  tendency  of  breast  cancer  to 
form  spinal  metastases.      In   29   cases  there  were  five  in  which 


SOCIETY  REPORTS. 

this  had  occurred.  The  suffering  was  intense.  The  possibility 
of  such  a  metastasis  was  a  strong  argument  for  early  operation 
on  the  primary  growth. 

The  President  said  that  primary  malignant  disease  of  the  spine 
was  rare  but  its  appearance  secondarily  was  not  uncommon.  In 
the  latter  c^.se,  if  the  pain  was  severe,  the  diagnosis  could  gen- 
erally be  made.  The  diagnosis  of  primary  new  growth  in  the 
spine  was  more  difficul:,  but  could  usually  be  made  by  watching 
the  course  of  the  c  ise.  There  was  usually  great  pain  and  often 
paraplegia,  so  that  the  nsim^  paraplegia  dolorosa  had  been  applied 
to  the  disease.  There  was  no  pain  more  severe.  If  the  patient 
developed  pain  in  the  spine  after  having  had  a  tumor  removed 
there  was  probably  a  location  of  the  disease  in  the  spine, 
although  the  surgeon  who  operated  might  not  want  to  admit  it. 

Dr.  S.  Lloyd  had  operated  for  the  removal  of  an  hydatid  tumor 
of  the  spine  in  a  case  which  the  diagnosis  had  long  been  un- 
certain. There  was  a  distinct  kyphosis  and  among  the  symp- 
toms had  been  pain  in  the  lumbar  region,  partial  sensory  and 
complete  motor  paralysis,  vasomotor  disturbances,  sphincter 
paralysis  and  cystitis.  The  patient  had  been  treated  by  a  num- 
ber of  surgeons  for  tubercular  disease  of  the  spine.  Nine  years 
from  the  beginning  of  the  symptoms  the  tumor  was  discovered 
and  removed  from  between  the  processes  of  the  8th  and  9th 
dorsal  vertebrae  where  the  adjacent  bones  were  eroded.  The 
paralysis  disappeared  and  the  man  went  back  to  his  trade.  A 
few  months  later  he  died  paraplegic  after  being  crushed  in  a 
railroad  accident.  The  spine  was  fractured  and  at  the  autopsy 
two  hydatid  cysts  were  found  in  the  cauda  equina. 

Dr.  Myers  said  that  gonorrhoeal  inflammation  of  the  spine 
was  a  rare  affection  and  that  typhoid  spine  was  more  common, 
depending  on  an  inflammation  of  the  periosteum  or  other  fibrous 
structures.  Infectious  inflammations  of  the  spine  followed  at- 
tacks ol  the  infectious  diseases  of  childhood.  He  gave  histories 
of  two  cases  in  which  wry-neck,  not  differing  from  that  of  ver- 
tebral caries  had  disappeared  without  sequel  after  treatment  by 
the  application  of  a  brace  with  a  chin-piece. 

Dr.  Sayre  had  seen  only  one  case  of  gonorrhoeal  disease  of 
the  spine.  The  history  was  clear  and  there  were  pain  and  dis- 
ability of  the  spine,  a  slight  kyphosis   and  stiffness  in  the  other 


2  24  SOCIETY  REPORTS. 

joints.  He  had  seen  a  few  cases  in  which  erosion  by  an  aneurism 
with  marked  kyphosis  had  been  confounded  with  Potts'  disease. 
Cases  were  on  record  in  which  suspension  for  the  reduction  of 
the  kyphosis  had  been  followed  by  rupture  of  theaneurismal  sac 
and  death. 

The  F resident sdixd  that  several  such  cases  had  come  under  his 
observation  which  had  been  supposed  to  be  tubercular  disease 
of  the  spine.  In  one  the  patient  suddenly  fell  back  in  bed  and 
expired. 

Dr.  Myers  said  the  traumatic  inflammation  of  the  spine  was 
seen  in  adults  more  often  than  in  children  and  was  usually  the 
result  of  considerable  violence.  The  kyphosis  was  not  often 
significant.  An  abscess  sometimes  followed  and  the  symptoms 
might  include  pain  in  the  spine,  not  anteriorly,  great  disability, 
muscular  twitching  and  exaggerated  knee  refiex.  The  progno- 
sis was  good  except  in  severe  injuries.  Fracture  should  be  care- 
fully protected  and  for  along  time. 

Dr.  Lloyd  said  that  the  violence  might  cause  tearing  of  the 
muscles  and  possibly  an  infected  inflammatory  area  with  rigidity 
but  without  kyphosis.  There  might  be  paralysis  below  the 
point  of  injury  with  rectal  and  vesical  symptoms  and  in  some 
cases  an  abscess  with  finally  good  recovery.  In  other  cases  a 
greater  degree  of  violence  produced  partial  dislocation  or  frac- 
ture, with  or  without  kyphosis.  In  these  cases  the  crepitus  was 
especially  important  as  symptoms  of  compression  of  the  cord 
might  not  appear  till  tv/o  or  three  weeks  after  the  injury. 

Dr.  G.  J^.  Elliott  said  that  when  we  had  a  distinct  lesion  of 
the  spine  such  as  fracture  of  the  vertebrae,  laceration  of  the 
ligaments,  extra-dural  hemorrhage,  the  cord  itself  escaping, 
together  with  clearly  demonstrable  objective  signs  such  as  possi- 
ble bony  changes,  muscular  atrophy,  some  motor  paralysis  and 
distinct  electrical  degenerative  reactions,  we  had  a  condition 
far  from  common  and  one  very  much  more  valuable  in  a  med- 
ico-legal sense  than  the  neurotic  symptom-group  called  railway 
spine  which,  when  standing  alone  and  unsupported  by  objective 
signs,  admits  of  endless  neurological  speculation. 

The  President  re.ca.\\Q6.  the  case  of  a  woman  who  had  been  shot 
in  the  mouth  with  a  blank  cartridge.  Stiffness  of  the  neck  and 
spinal  paralysis  developed  and  the  autopsy  showed  suppuration 
running  down  the  cervical  vertebrae  beneath  the  peiiosteum  and 


SOCIETY  REPORTS.  ,  -  - 

into  the  inter-vertebral  foramina  with  a  secondary  inflammation 
of  the  cord.  Also  the  case  of  a  boy  who  has  been  kicked  over 
the  sacrum  and  who  was  suffering  from  what  was  supposed  to 
be  spinal  meningitis.  An  autopsy  showed  necrosis  of  a  portion 
of  the  inner  surface  of  the  sacrum  with  exudate  outside  of  the 
dura  mator  but  running  along  the  roots  of  the  nerves  and  also 
an  inflammation  with  exudate  intradural  and  subarachnoid. 

Dr  Toivnsend  said  that  instances  of  non-tubercular  inflam- 
mation of  the  spine  were  extremely  rare  in  comparison  with  the 
vast  numberof  tubercular  cases  which  came  under  observation 
and   treatment. 

Dr  A.B.Judson  said  that  whei':  a  patient  complained  of  spinal 
pain  and  spinal  disability,  the  first  thought  was  to  exclude  Pott's 
disease.  It  was  strange  that  these  symptoms  were  not  found  in 
a  condition  so  closely  simulating  fracture  or  the  worst  type  of 
traumatism.  On  the  other  hand,  in  the  non-tubercular  inflam- 
mation as  a  rule  spinal  disability  and  pain  were  early  and  prom- 
inent symptoms,  marking  a  frank  and  sometimes  alarming  onset 
very  different  from  the  long  continued  and  insidious  approach 
of  vertebral  caries. 

Dr.GibneyiQS.^  that  we  were  not  apt  to  look  for  tuberculous 
diseases  of  the  spine  in  adults  while  they  were  very  frequent  in 
children. 

The  President  said  that  the  possibility  of  making  a  mistake 
should  be  borne  in  mind,  for  instance  in  an  injury  occurring  in 
a  man  who  was  both  tubercular  and  syphilitic.  The  only  way 
was  to  go  overall  the  points  of  each  disease  and  exclude  as  many 
as  possible,  not  forgetting  that  two  diseases  might  be  present  in 
the  same  patient. 

Dr.MyQ.rs  said  that  if  a  patient  were  curable  within  a  year  the 
diagnosis  of  tuberculous  spondylitis  should  be  re-considered. 
From  a  medico-legal  standpoint  it  was  important  to  remember 
that  a  considerable  number  of  chronic  and  increasing  kyphoses 
were  not  tubercular  in  their  origin  and  that  such  disabilities 
should  not  be  rated  so  high  in  awarding  damages  as  those  which 
were  tubercular.  In  life  insurance,  also,  applicants  with  non- 
tubercular  impairment  of  the  spine  should  have  a  more  favorable 
consideration  than  those  whose  disability  had  a  tubercular  origin  . 


NORTH  CAROLINA  IVIEDZCAL  JOURNAL, 

ROBERT  D.   JEWETT,  M.D.,  Editor 


DEPARTMENT  EDITORS 

(      H.  T.  Bahnson,  M.D..  Salem.  N.C. 
SURGERY:     -      R.  L.  Gibbon. M.D.,  Chavlotte.  N.  C. 

f     J.  Howell  W  ay,  M.D.,  Wayuesville,  N.  C. 

NERVOUS  DISEASES:— J  ^llison  Hodges,  M.D.,  Rcilimond,  Va, 
PRACTICE  OF  MEDICINE.  I    S.  V/estby  Batti^.  M.D.,  U.  S.  K 


OBSTETRICS: 


George  G.  Thomas,  M.D.,  Wilmington,  N.  C. 
R.  L.  Payne,  M.D.,  Norfolk,  Va. 


(      H.  S.  LOTT,  M.D..  Winston.  N.  C. 
GYNAECOLOGY:      \      J.  W.  Long.  M.D.,  Salisbury.  N.  C. 
(      H.  A.  ROYSTER,  M.D.,  Raleigh,  N.  C. 

PATHOLOGY:— Albert  Anderson,  M.D.,  Wilson,  N.  C. 

PEDIATRICS:— J.  W.  P.  Smithwick,  M.D.,  La  Grange,  N.  C. 

TRANSLATION  AND  FOREIGN  REVIEWS: 

Richard  H.  Whitehead,  M.  D.,  Chapel  Hill,  N.  C. 


All  communications,  either  of  a  literary  or  business  nature,  should  be 
addressed  to,  and  any  remittances  by  P.  O.  Order,  Draft  or  Registered  Let- 
ter, made  payable  to  Robert  D.  Jewett,    M.D.,  Winston,  N.  C. 


B3t)itonaL 


STATE  PRODUCTION   OF  DRUGS. 


There  has  recently  been  considerable  discussion  in  the  medical 
press  in  regard  to  the  action  of  the  City  of  New  York  in  under- 
taking to  produce  antitoxin.  It  is  clearly  the  duty  of  a  munic- 
ipality to  u;>e  every  means  within  its  power  to  prevent  the  spread 
of  infectious  diseases.  It  has  been  clearly  and  conclusively  dem- 
onstrated that  antitoxin  acts  both  as  a  curative  and  preventive 
agent  in  diphtheria.  It  is  then,  important  as  regards  the  welfare 
of  the  commuity,  that  it  be  made  available  for  use  in  tlie  poorer 
classes.  At  the  present  prices  it  is  absolutely  beyond  their  ability 
to  purchase  it.      Then  it  should  be  provided  by  the  city  or  county. 


i!j<Jiiuui2\ij.  227 

But  how  shall  the  city  or  county  do  this?  By  establishing 
laboratories,  buying  horses,  employing  bacteriologists,  and  ap- 
pointing agents  for  its  distribution  to  those  who  are  attacked,  or 
in  danger  of  being  attacked,  by  the  disease  and  who  are  unable 
to  purchase  the  remedy?  This  would  be  a  big  undertaking  and 
unless  the  quanity  to  be  used  was  very  large,  would  cause  the 
cost  per  dose  to  be  very  great.  In  regard  to  the  experiment  by 
the  New  York  Health  Department,  Dr.B.I.Whitmore,  in  an  arti- 
cle in  the  Bulletin  of  Pharmacy  makes  the  statement  that  the 
antitoxin  made  by  the  city  at  a  cost  of  $60,000  would  not  have 
cost  more  than  $10,000  if  made  under  other  than  municipal 
auspices.  There  are  numerous  concerns  in  this  country  and 
Europe  which  manufacture  antitoxin,  and  whose  facilities  ena- 
ble, and  whose  reputation  require,  them  to  dispense  preparations 
as  nearly  perfect  as  it  is  possible  to  make  them. 

There  seems  to  be  as  much  reasf'U  for  the  State  to  engage  in 
the  manufacture  of  quinine,  or  shoes,  or  clothing,  as  to  enter 
the  market  for  the  manufacture  of  these  preparations  which  be- 
longs legitimately  to  the  pharmacutical  laboratories. 


ELECTION  OF  MEMBERS    TO  THE    BOARD  OF  MED- 
ICAL EXAMINERS. 


Among  the  most  important  things  to  be  done  at  the  coming 
meeting  of  the  State  Society,  is  the  election  of  two  new  members 
to  the  Board  of  Medical  Examiners,  to  fill  the  vacancies  caused 
by  the  expiration  of  the  terms  of  office  of  Dr.  Julian  M.  Baker, 
ot  Tarboro,  and  Dr. H.B.  Weaver,  of  Asheville.  These  gentlemen 
were  elected  in  1892  for  a  term  of  six  years.  Both  have  pioven 
faithful  to  the  trust  bestowed  upon  them.  During  the  last  two 
years  these  gentlemen  have  acted  respectively  in  the  capacity  of 
President  and  Secretary  of  the  Board;  they  have  been  constant 
and  interested  attendants  upon  each  meeting  of  the  Board  except 
in  the  event  oi  sickness,  and  deserve  the  hearty  thanks  of  the 
Society  for  their  conscientious  attention  to  duty. 

The  new  members  will  be  elected  for  a  term  of  four  years,  in 


2  28  REVIEWS    AND  BOOK   NOTICES. 

accordance  with  the  resolutions  adopted  by  the  Society  in  1896, 
which  provides  that  the  terms  of  all  six  members  of  the  Board 
shall  expire  in  1902,  looking  to  a  return  to  the  former  plan  of 
electing  the  entire  Board  once  each  six  years. 


A  SERIES  OF  CLINICAL  LECTURES  ON  GYNE- 
COLOGY. 


We  are  pleased  to  announce  that  we  have  made  arrangements 
with  Dr.  Augustine  H.  Goelet  for  a  series  of  Clinical  Lectures 
on  Operative  Gynaecology,  which  he  is  delivering  at  the  Man- 
hattan Hospital.  Dr.  Goelet  is  Professor  of  Gynaecology  in 
the  New  York  School  of  Clinical  Medicine,  and  has  made  an 
enviable  reputation  in  New  York  City  in  this  branch  of  surgery, 
and  our  readers  will  undoubtedly  appreciate  this  opportunity 
of  following  him  in  a  series  of  diversified  and  interesting  cases. 
The  first  of  the  series  appeared  in  the  last  issue  of  the  Journal, 
being  a  lecture  on  Shortening  of  the  Round  Ligaments  by  a 
New  Method  for  Reducible  Retroflexion  of  the  Uterus.  The 
next  lecture  will  appear  in  the  issue  of  April  20th — Conserva- 
tive Oophorectomy — Prolapsus  of  the  Uterus  Complicated  with 
Broad  Ligament  Cyst. 


1Re\)ie\x)0  anb  Book  IRotices. 

Natural  History.  By  R.  Lydekker,  B.  A.,  F.R.S.,  V,P.G.S.;W. 
F.  Kirby,  F.L.S.,  F.E.S.;B.  B.  Woodward,  F.L.S.,  F.G.S.;  R.  Kirkpatrick; 
R.  I.  Pacock;  R    Bowdler  Sharpc,  LL.D.;  W.  Garstang,  M.A.,  F.Z.S.;  F.  A. 

Bather,  M.A.,  F.G.S.;  H.  M.  Bernard,  M.A.,  F.L.S.     Octavo,  cloth,  pp  772. 
D.  Appleton  &  Co.,  New  York.     1897. 

This  is  a  concise  and  accurate  Natural  History  and  would  be 
a  useful  addition  to  every  library.  The  several  departments 
are  treated  by  men  who  have  made  a  specialty  of  the  subject 
upon  which  they  have  written,  and  who  have  done  much  original 
investigation  The  volume  is  fully  illustrated  and  supplied  with 
both  a  systematic  and  alphabetical  index. 


CURRENT   LITERATURE.  2^ 

The  International  Medical  Annual  and  Practitioner's  index,  a 

work    of    Reference   for    Medical    Practitioners.     Sixteenth    year.     Octavo, 
cloth,  pages  740.     Price  $3.00.      E.  B.  Treat  &  Co.,  New  York.      1S98. 

This  work  has  become  the  daiiy  friend  of  the  practitioner.  Is- 
sued early  in  the  year  it  keeps  its  readers  informed  in  regard  to 
the  latest  and  best  methods  of  treatment.  The  work  is  entrusted 
to  the  hands  of  careful  and  able  men,  and  they  have  never  done 
their  work  better  than  in  the  present  volume.  Part  I,  of  the 
present  edition  is  devoted  to  a  review  of  new  remedies,  electro- 
therapeutics, hypnotism  and  suggestion.  Then  follows  the  main 
part  of  the  work,  being  a  dictionary  of  new  treatment  in  medicine 
and  surgery.  Following  this  is  a  useful  atlas  of  the  bacteria 
pathogenic  to  man.  This  is  illustrated  by  colored  plates  and 
description  of  methods  used  in  cultivating  and  staining.  The 
volume  closes  with  short  chapters  on  legal  decisions,  sanitary 
science,  cjnccaled  alcohol  in  drugs,  new  inventions,  and  a  list 
of  the  most  important  medical  books  published  during  the  year. 


IRcplew  of  Current  Xitcrature, 


GENERAL  SURGERY. 

IN  CHARGE  OF 

H.  T.  Bahnson,  M.D.,  R.  L.  Gibbon,  M.D. 

J.  Howell  Way,  M.D. 


Appendicitis. — Appendicitis  should  be  operated  on  as  soon  as  the 
diagnosis  is  made,  is  the  radical  opinion  of  Dr.  R.  T.  Morris  (corre- 
spondence, Jour.  Am.  Med.  Asso. ,  March  1898)  who  has  g-iven  us  one 
of  the  most  extreme  volumes  we  have  in  advocacy  of  cutting  in  all 
cases.     He  epitomizes  his  present  views  as  follows: 

1.  No  physician  will  ever  be  able  to  prejudicate  upon  the  extent  of 
bacterial  ravages  in  any  given  case  of  appendicitis. 

2.  If  we  wait  to  see  whether  a  mild  case  is  to  remain  a  mild  case,  the 
cases  that  are  not  mild  become  complicated  cases  before  operation  is 
done  and  we  then  have  an  unnecessary  death  rate,  an  unnecessary  suf- 
fering rate,  an  unnecessary  loss  of  time  rate. 

3.  Operations  properly  performed  as  the  outset  of  infective  appendi- 


2  ,o  CURRENT    LITERATURE. 

citis  have  a  smaller  loss  of  time  rate,   a  smaller  suffering  rate  and  a 
smaller  death  rate  than  can  be  given  by  any  sort  of  medical  treatment. 

4.  Operations  perfoi^med  properly  by  the  surgeon  when  bacteria  are 
causing  progressive  destruction  of  tissues  outside  of  the  appendix,  are 
less  dangerous  than  the  operations  that  the  bacteria  perform. 

5.  Operations  performed  properly  when  patients  are  apparently  con- 
valescing from  acute  appendicitis,  avoid  the  surprises  that  appear  in 
the  form  of  infective  phlebitis,  portal  embolism  and  other  naetastatic 
complications  which  are  so  often  observed  by  those  of  us  who  are  en- 
gaged in  appendicitis  work. 

6.  Operations  performed  properly,  in  the  interval  between  attacks  of 
appendicitis,  give  results  similar  to  those  performed  in  the  early  infec- 
tion stage. 

I  believe  that  it  will  be  an  easy  matter  to  refute  any  arguments  to 
the  contrary  of  my  proposition,  but  I  would  like  very  much  to  have 
the  matter  discussed  very  promptly  because  patients  are  hourly  dying 
unnecssarily  from  appendicitis,  and  it  is  high  time  that  a  pr-eventable 
death  rate  be  prevented. 

[All  of  which  is  very  interesting  and  readable.  What  has  Morris 
ever  written  that  was  not  readable  and  interesting?  But  the  metropol- 
itan surgical  specialists  and  teachers  will  have  a  difficult  field  to  till  in 
seeking  to  engraft  such  extreme  views  upon  the  common,  every-day 
general  practitioners,  who  after  all  do  the  bulk  of  the  treating  of  human 
disease.  On  March  14,  1888,  the  writer  did  his  first  celiotomy  for  ap- 
pendicitis. The  patient  made  an  excellent  recovery.  In  the  ten  years 
since  then  he  has  treated  upwards  of  40  cases — the  majority  being  seen 
through  the  courtesy  of  colleges.  The  majority  have  not  been  sub- 
jected to  operation.  Of  the  cases  operated  upon,  more  than  70  per 
cent,  have  recovered.  No  case  has  died  without  operation  being  per- 
formed, even  when  in  some  cases  it  was  evident  that  a  fatal  result  was 
inevitable.  Yet  it  is  to-day  his  calm  deliberate  judgment  that  the  pro- 
fessional teachers  and  writers,  in  the  main,  have  gone  entirely  too  far 
in  the  matter  of  operations  for  appendicitis.  The  majority  of  all  cases 
will  recover  without  operation,  and  the  greater  number  of  them  will 
remain  permanently  free  from  any  recurrence  of  the  disease.  The  '  'ex- 
perience" of  one  man  is  always  a  very  little  thing  to  be  influenced  by 
—yet  after  ten  or  fifteen  years  in  practice  a  man  is  wholly  unfit  to 
prastice  medicine  who  has  not  pretty  firmly  established  certain  things 
in  his  own  mind. 

The  great  Sir  Astley  Cooper  compared  the  magnificent  clinical  expe- 
rience it  had  been  his  good  fortune  to  have  to  "only  a  tiny  drop  in  the 
vast  ocean  of  surgery,"  hence  the  writer  submits  his  opinion  with 
much  diffidence,  yet  he  feels  that  it  is  now  time  for  the  general  practi- 
tioner to  "have  his  say"  on  the  appendicitis  question.]         J.  H.  W. 

The  Surgical  Treatment  of  Gastric  Ulcer  is  the  title  of  an 
interesting  clinical  report  (Jour.  Am.  Med.  Asso.,  March  1898)  by  Dr. 


CURRENT  LITERATURE.  2  ?  r 

Knott.     The  case,  a  female  ag-ed  32  consulted  the  doctor  for  severe 
gastralgia  and  digestive  disturbance  of  a  year's  standing. 

She  complained  of  very  acute  abdominal  pain  coming  on  soon  after 
eating,  which  was  frequently  attended  with  vomiting.  Coughing, 
sneezing,  etc.,  were  attended  by  the  most  excruciating  pain.  She  had 
been  constantly  under  treatment  for  one  year,  her  ailment  being  diag- 
nosed as  dyspepsia,  and  was  almost  discouraged  concerning  her  con- 
dition. Owing  to  the  difficulty  with  which  food  was  retained  in 
stomach,  she  was  extremely  emaciated.  Temperature  v/as  the 
100,  pulse  85.  An  examination  of  the  abdomen  i-evealed,  upon  palpa- 
tion, n  tender  indurated  spot  about  one-half  an  inch  above  and  the 
same  distance  to  the  left  of  the  umbilicus.  This,  together  with  the 
symptoms  above  enumerated,  led  to  the  diagnosis  of  an  adhesion  be- 
tween the  stomach  and  the  abdominal  wall,  with  possibly  the  forma- 
tion of  an  abscess.  In  addition  to  the  usual  preparations  for  the 
celiotomy,  the  stomach  v/as  thoroughly  washed  out.  The  abdomen  was 
opened  in  the  median  line  and  the  adhesion  existing  between  the  ante- 
rior surface  of  the  stomach  and  the  abdominal  wall  was  readily  found. 
This  point  was  walled  off  from  the  surrounding  tissues  with  gauze 
sponges  and  the  adhesion  separated,  keeping  close  to  the  abdominal 
wall.  No  pus  was  present  and  the  stomach  v/all  at  this  point  was 
found  to  be  intact,  the  ulcer  having  apparently  healed.  The  ulcerated 
area,  however,  was  folded  in  and  retained  by  close  suturing.  As  no 
abscess  existed  and  the  stomach  had  not  been  opened  the  abdominal 
incision  was  closed  without  drainage.  The  troublesome  symptoms  im- 
mediately disappeared  and,  fifteen  months  after  operation,  had  not  re- 
curred. The  patient  rapidly  regained  her  lost  weight  and  has  since 
been  in  perfect  health.  J.  H.  W. 

The  Conservative  Agency  of  Shock. —Wetherill  (Jour.  Am. 
Med.  Asso.,  March  189S)  from  a  thoughtful  study  of  the  phenomena  of 
shock  deduces  these  suggestive  conclusions: 

1.  Surgical  shock  entirely  unassociated  with  hemorrhage  is  a  condi- 
tion rarely  seen  and  one  which  may  usually  be  successfully  treated  in 
persons  who  are  otherwise  in  good  health. 

2.  Hemorrhage  though  small  in  amount  is  a  far  more  important  fac- 
tor in  the  production  of  surgical  shock  ( as  it  is  seen  clinically)  than 
we  have  been  accustomed  to  think  it . 

3.  This  mixed  shock  (traumatic  asthenia)  should  be  designated  by 
some  distinctive  title,  or  the  term  shock  be  construed  to  comprehend 
all  the  factors  in  its  genesis. 

4.  While  not  proven  it  seems  probable,  that  the  effects  of  even  a 
small  continuous  arterial  hemorrhage  is  to  produce  through  its  reflex 
action  lower  blood  pressure  and  in  general  a  condition  so  like  true 
shock  as  to  be  very  difficult  of  differentiation,  particularly  if  the  hem- 
orrhage is  concealed;  as  in  ruptured  ectopic  pregnancy. 


232 


C  URRENT  LITER  A  T  U  RE. 


5.  Surgical  shock,  with  or  without  hemorrhage,  must  be  construed 
as  primarily  conservative  in  its  tendencies.  The  incident  prevention 
of  rapid  exhaustion,  of  acute  suffering,  or  great  blood  loss  when  the 
blood  vessels  are  opened,  all  tend  to  the  ultimate  saving  of  life. 

6.  Premature  stimulation  in  the  treatment  of  traumatic  asthenia  may- 
defeat  this  conservative  effort  of  nature.  Bleeding  should  be  stopped 
and  proper  provision  made  for  the  comfort  and  welfare  of  the  patient 
before  strong  stimulation  is  resorted  to,  unless  there  is  imminent 
danger  of  death. 

7.  Anesthetics  must  be  sparingly  and  cai-efully  given  to  patients 
suffering  from  surgical  shock  (traumatic  a-sthenia),  chiefly  because  they 
completely  obliterate  the  reflexes.  The  saturation  of  the  patient  with 
an  anesthetic  may  turn  the  scale  against  him  even  though  the  direct 
effect  of  the  anesthetic  be  stimulant.  The  same  rule  holds  good  in  re- 
gard to  the  employment  of  alcoholic  stimulants  if  too  freely  used. 

8.  "We  should  co-operate  with  and  supplement  nature's  conservative 
efiorts.  They  are  always  exercised  in  behalf  of  the  patient,  never 
against  him.  J.  H.  W. 

Surgical  Intervention  in  Perforting  Peritonitis  from 
Typhoid  Fever. — Monod,  (Am.  Med.  Asso.  Jour.,  quotation  from 
Cbl.  f.  Chir.,  March  1898)  reports  a  case  in  which  he  performed  lapar- 
otomy, but  the  patient  died  three  days  later,  as  the  peritonitis  continued 
its  ravages.  He  has  had  five  recover  out  of  thirty-two  operated  on  in 
these  conditions,  an«i  considers  an  operation  indicated  and  justified  as 
a  last  resort.  Routier,  Brun  and  Lejars  have  each  a  record  of  one  or 
two  cases  thus  treated,  but  none  recovered.  J.  H.  W. 

Ajniputations  of  Extremeties  without  Ligatures.— O.  R.  Bar- 
ber (Medical  Age)  describes  a  method  of  closing  the  wounds  in  ampu- 
tations without  the  use  of  ligatures,  and  in  which  he  claims  original- 
ity. After  rendering  the  limb  bloodless  with  the  elastic  roller  bandage, 
the  amputation  is  completed  and  the  flaps  adjusted.  With  a  long  piece 
of  aseptic  catgut  he  then  stitches  into  the  muscle  next  the  bone  at  one 
edge  of  the  wound,  and  sews  back  and  forth,  the  same  as  any  wound 
is  closed  by  deep  buried  sutui'es;  bringing  the  muscular  tissue  into 
snug  apposition,  but  not  too  tightly,  and  when  getting  to  the  outer 
edge  whips  the  outer  and  last  rows  of  stitches  by  the  over-and-over 
method,  so  that  the  muscular  tissue  is  smoodi.  round  iiud  compact. 
Then  the  skin  is  brought  over  and  stitched  over  all.  The  "Esmarch'" 
is  then  removed.  He  claims  to  have  used  this  method  in  six  amputa- 
tions of  the  lower  exire'nity  for  crushing  injury  during  the  last  four 
months,  and  in  no  case  has  there  been  even  a  drop  of  hemorrhage.  The 
results  have  been  very  favorable  in  giving  a  rounded,  painless  stum]). 


PATHOLOGY. 

in  charge  of 
Albert  Anderson,   M.  D.,   Wilson,   N.  C. 


Ijmmunity.— The  results  from  sero-therapy  and  sero-diagnosis  within 
the  last  three  years  have  been  remarkable  and  former  theories  of  im- 
munity from  infectious  diseases  have  been  greatly  modified  by  these 
results.  Formerly  we  looked  upon  immunity  as  of  two  kinds,  natural 
and  acquired,  and  now  to  these  we  may  add  an  artificial  type— "for  of 
immunity,  as  of  g-reatness,  it  may  be  truly  said:"  "Some  are  born 
immune,  some  achieve  immunity  and  same  have  immunity  thrust  upon 
them."  Natural  immunity  is  supposed  to  be  due  to  "alexins,  which 
are  germicidal  proteids,  of  general  character,  without  specific  action, 
and  universally  present  in  all  animals  which  are  either  actively  or 
passively  immunized."  These  alexins  are  in  the  blood.  Whence  did 
they  come?  Perhaps  by  inheritance.  If  we  have  a  true  history  of  men 
and  animals  that  are  so-called  naturally  immunized  to  certain  infectious 
diseases,  we  might  find  out  that  this  was  only  acquired  immunity  which 
had  been  transmitted  through  the  generations. 

Metschnikoff's  theory  of  immunity  by  the  germ-devouring  action  of 
certain  voracious  leucocytes,  by  this  action  termed  phagocytosis,  was 
easily  comprehended,  pretty  and  plausible.  But  this  theory  has  not 
withstood  the  test  of  further  experimentation  by  such  men  as  Mettall 
who  was  the  first  to  give  it  a  severe  blow.  He  showed  very  plainly 
that  the  leucocytes  were  not  essential  to  the  destruction  of  virulent 
bacteria  in  the  blood,  but  that  the  serum,  with  the  cellular  elements 
eliminated,  possessed  equal  germicidal  ability.  It  probably  is  a  fact 
that  the  leucocytes  manufactui-e  substances  that  are  inimical  to  the 
germs  and  these  circulate  in  the  blood  and  attack  the  germs  at  a  dis- 
tance from  the  leucocytes. 

In  typhoid,  diphtheria,  cholera,  pneumonia,  dysentery  and  others. 
we  know  that  bacteria  producing  these  are  physiologically  outside  of 
the  body,  because  they  do  not  enter  the  blood,  lymph  or  tissues.  We 
find  them  anatomically  within  the  alimentary  canal  and  air  passages 
but  physiologically  outside  of  tissues  mentioned  above.  At  different 
places  they  are  localized  and  there  do  the  work  of  forming  toxins  and 
these  enter  the  blood,  lymph  and  tissues,  and  the  leucocytes  have  only 
one  point  of  attack  on  the  bacteria,  in  the  throat  in  diphtheria,  in  the 
intestinal  glands  in  typhoid  and  likewise  in  others.  As  it  is  said  by 
Thompson,  "it  is  clearly  impossible  for  leucocytes  to  cause  immunilf^- 
by  phagocytosis  in  such  instances,  although  it  may  be  admitted  that 
exceptionally,  where  the  germs  tend  to  invade  the  blood  or  viscera, 
there  may  be  something  of  a  battle  royal  between  the  leucocyte  and 
bacillus.     Even  in  such  cases,  is  it  not  possible  that  the  leucocyte  first 


2  ,A  CURRENT    LITERATURE. 

kills  the  germ  at  a  distance  by  means  of  some  secretion  and  then  de- 
vours it  as  a  foreig-n  body"?" 

The  antitoxin  theory  of  immunity  is  one  that  has  (some  to  stay, 
though  there  is  a  great  deal  to  be  learned  about  it  yet.  Antitoxins  act 
either  as  chemical  antagonists,  i.e.,  by  neutralization  of  toxins,  or  as 
physiological  antagonists,  i.e.,  by  stimulating  the  cells  ot  the  body  to 
increased  resistance.     Dr.  Thompson  says: 

"The  poison  of  any  infection  must  necessarily  pass  through  the 
blood  or  lymph  in  order  to  reach  the  body  tissues  generally;  hence  it 
is  a  distinct  gain,  both  in  point  of  time  and  substance,  to  have  its  ac- 
tion neutralized  in  the  blood  serum.  The  "resistance  of  "tissues"  is, 
after  all,  a  somewhat  vague  phrase,  and  any  definite  knowledge  of  how 
to  increase  this  resistance  artificially,  and  thei-eby  ])roduce  immunity, 
is  la^cking'.  The  phagocytosis  theory  deals  with  the  germs  rather  than 
their  toxins.  The  toxins  may  have  been  formed  before  the  phagocy- 
tosis can  act,  and,  moreover,  we  possess  no  reliable  means  of  produc- 
ing immunity  through  stimulation  of  phagocytosis.  The  theory  of  ex- 
haustion of  the  soil  in  which  the  germs  grow  presupposes  the  complete 
development  of  the  infection.  But  serum  which  is  antitoxic,  whether 
so  i-endered  artificially  or  naturally,  is  the  ideal  immunizing  agent:  for 
it  is  independent  of  tissues,  it  is  universally  present  in  the  body,  and 
before  either  phagocytosis  or  soil  sterilization  or  exhaustion  has  time 
to  act  it  opposes  the  toxin  as  fast  as  formed,  so  that,  as  for  example, 
in  diphtheria,  the  antitoxin  practically  cures  the  disease  and  immunizes 
the  patient  long  before  the  bacilli  have  left  the  throat.  The  blood 
serum,  which  is  the  chief  transmitter  of  infection,  thus  becomes  its 
chief  antagonist.  From  the  data  thus  fa,r  accumulated,  however,  it 
would  appear  that  artificial  antitoxin  immunity  is  not  so  strong 
or  so  lasting  as  natural  immunity,  thus  rendering  reinoculation 
desirable  in  time  of  exposure.  This  is  true  even  of  small-pox  and 
vaccinia.  No  one  would  think  of  the  revaccination  of  a  patient 
who  had  had  a  typical  attack  of  small-pox,  for  immunity  is  practically 
permanent.  W.  M.  Welch  says  that  "no  person  during  the  last  quarter 
of  a  centui'y  has  been  admitted  to  the  Philadelphia  Municipal  Hospital 
twice  suffering  from  the  disease. ' ' 

"Yet  we  know  that  the  immunity  against  variola  produced  by  vac- 
cinia (which  is  in  all  probability  due  to  an  antitoxin  formed  in  the 
blood  after  inoculation  with  this  latter  disease)  must,  in  order  to  be- 
come permanent,  be  renewed  several  times  after  intervals  of  a  half- 
dozen  years.  The  artificial  immunity  established  by  inoculations  of 
tetanus  antitoxin,  diphtheria  antitoxin,  antistreptococcus  serum,  etc., 
is  far  from  permanent.  A  protective  inoculation  of  three  hundred  diph- 
theria antitoxin  units  confers  immunity  in  man  of  but  from  three  to 
eight  weeks  (Park).  Paterson,  of  Glasgow,  procured  artificial  im- 
munity in  fowls  from  fowl  tuberculosis  which  persisted  for  only  five 
months.  Powell,  in  a  summary  of  all  the  published  experiments  in 
India  in  anticholera  inoculations,  concludes  that  doses  large  enough 


CURRENT  LITERATURE.  2-IC 

to   occasion  decided  febrile  movement  seem  to  confer  immunity,  but 
that  smaller  doses  confer  very  brief  if  any  protection. 

Attractive  as  is  the  question  of  immunity  by  antitoxins,  it  yet  leaves 
ma.ny  facts  unexplained.  It  of  course  does  not  account  for  natural  or 
congenital  immunity  in  distinction  from  that  conferred  by  a  single  at- 
tack of  an  infectious  disease.  During  the  prevalence  of  an  epidemic, 
doubtless  many  persons  escape  infection  merely  because  the  specific 
germs  do  not  happen  to  find  entrance  to  the  body  at  a  propitious  timt^ 
for  this  development." 


GYNECOLOGY  AND  ABDOMINAL  SURGERY. 

IN  CHARGE  OF 

H.  S.  LoTT,  M.  D.,  J.  W.  Long,  M.  D., 

Hubert  A.  Rovster,  M.  D. 


Ruptured  Tubal  Pregnancy.— A  Lapthorn  Smith  (American  Jour,  of 
Surg,  and  Gynae. )  reports  in  full  a  case  which  is  of  interesc  as  showing  the 
extreme  degree  of  peril  from  which  surgery  saved  the  patient.  "On  the 
night  of  2nd  of  December  while  on  her  way  to  the  closet,  something  broke 
inside  and  she  fell  in  a  faint.  She  was  put  to  bea  and  revived,  but  was  in 
greet  pain  all  night,  and  next  day  Dr.  G.  T.  Ross  was  called  in.  He  found 
a  woman  with  a  blanched  face,  a  pulse  of  12?,  and  a  temperature  of  loi;^. 
Her  respiration  was  normal  but  her  countenance  was  anxious,  and  she -was 
sweating  profusely.  There  was  constant  nausea  and  vomiting,  and  great 
tenderness  over  right  side  of  abdomen  extending  to  the  epigastrium.  No 
tumor  could  be  felt  either  by  palpation  of  the  abdomen  or  by  digital  exam- 
ination. Although  the  right  vaginal  fornix  was  very  tender,  no  tumor  could 
be  made  out  there.  The  abdomen  was  resonant  and  even  tympanitic  every- 
where. Dr.  Ross  on!y  saw  this  patient  on  the  one  occasion  yet  taking  into 
consideration  her  previous  history  and  her  present  appearance,  he  at  once 
decided  that  rupture  of  an  extra-uterine  pregnancy  had  occurred,  and  that 
something  must  be  done  very  soon.  He  therefore  had  the  patient  sent  to 
the  Samaritan  Hospital  in  the  ambulance,  where  I  found  her  soon  after- 
wards. She  now  had  all  the  appearance  of  a  woman  with  hemorrhage,  and 
yet  there  was  no  evidence  of  tubal  pregnancy  to  be  obtained  by  local  exam- 
ination. With  the  hope  that  I  might  be  able  to  get  her  bowels  moved,  and 
the  distention  relieved,  and  the  pulse  improved,  I  delayed  a  day;  this,  how- 
ever, proved  unwise.  By  that  time  the  vomiting  had  become  fecal  and  the 
pulse  had  gone  up  to  150.     The  fecal  vomiting  led  mc  to  suspect  obstruction 


236  CURRENT   LITERATURE. 

of  the  bowel.  However  as  I  had  seen  Martin,  of  Berlin,  save  two  women 
whose  abdomens  were  full  of  blood,  and  who  were  moribund  and  operated 
on  without  any  anesthetic,  not  being  conscious,  I  decided  to  put  her  on  the 
table  and  operate  at  all  hazards.  Time  was  taken  to  make  the  field  of  oper- 
ation aseptic,  and  on  opening  the  abdomen  the  dark  blood  gushed  forth,  and 
on  introducing  the  hand,  the  abdomen  was  found  to  be  filled  with  clots,  the 
Intestines  being  pushed  to  the  front.  The  right  tube,  from  which  the  blood 
was  pouring,  was  at  once  seized  and  tied,  and  with  the  ovary  removed.  The 
tube  was  very  thin  and  small,  not  much  larger  than  normal;  the  placenta 
having  been  expelled  with  the  fetus  through  a  tear  in  the  side  of  the  tube. 
The  placenta  was  lost  among  the  clots.  The  quantity  of  clots  and  fluid 
blood  removed  was  estimated  by  my  assistant  to  be  between  three  and  four 
quarts.  After  this  had  been  removed,  the  abdomen  was  irrigated  with  a 
long  nozzle  and  clots  removed  from  beneath  the  stomach  and  liver.  Then  a 
gallon  of  hot  salt  solution  was  poured  in  and  left  in.  The  left  ovary  was 
found  adherent  but  was  not  disturbed.  In  addition  to  the  gallon  of  salt  so- 
lution introduced  at  the  operation,  she  had  three  quarts  more  by  enema  the 
same  day,  and  two  quarts  more  the  second  day,  making  nine  quarts  of  salt 
solution  retained  in  two  days.  This  brought  her  pulse  down  from  150  to  80 
per  minute.  This  patient  is  sitting  up  with  normal  pulse  and  temperature 
three  weeks  after  operation.  I  think  we  have  reason  to  be  proud  of  our  pro- 
fession when  we  see  a  general  practitioner  diagnose  accurately  and  at  once 
such  an  obscure  case.  Without  his  diagnosis  and  prompt  action  this  woman 
was  condemned  to  certain  death."  H,  S.  L. 

J.  E.  Andrew  (Australasian  Med.  Gaz.  May  20,  1897, — American  Gynse. 
and  Obstet.  Jour.)  reports  a  case  of  ectopic  gestation,  "not  so  much  on  ac- 
count of  its  rarity,  as  to  enforce  the  importance  of  immediate  operation  as 
soon  as  a  diagnosis  is  made.  Soon  after  midnight  Dr.  Andrew  was  sum- 
moned to  a  patient  whom  he  found  in  a  state  of  collapse  aud  suffering  great 
abdominal  pain.  The  history  was  largely  obtained  from  the  family.  The 
patient  had  been  married  five  months,  had  missed  one  period,  and  the  two 
previous  had  been  scanty.  There  had  been  a  little  morning  sickness  a 
month  ago,  and  slight  enlargement  of  the  mammary  glands.  A  week  before 
she  had  a  little  pain  in  the  abdomen,  but  so  slight  as  not  to  require  medical 
advice.  But  at  g  o'clock  the  previous  evening  she  complained  of  a  sudden 
pain  about  the  navel,  felt  faint  and  vomited  slightly.  She  went  to  bed,  the 
pain  increasing  so  that  she  screamed  aloud.  When  seen  a  little  after  12 
o'clock,  she  looked  as  if  dying.  Extremities  cold  and  clammy,  pupils  di- 
lated, radial  pulse  absent,  but  the  heart  seemed  to  be  doing  fairly  well.  The 
abdomen  was  slightly  distended  and  a  little  tender,  there  was  dullness  on 
each  side  and  half  way  up  to  the  umbilicus.  The  uterus  was  low  in  the 
vagina  but  not  enlarged,  nor  was  there  any  discharge;  there  was  a  feeling 
of  fluid  in  Douglas'  pouch.  These  conditions,  together  with  the  history, 
led  to  a  diagnosis  of  ruptured  tubal  pregnancy.  Dr.  Anderson  v-as  sum- 
moned, with  a  view  to  removing  the  extra-uterine  pregnancy,  with  the  ap- 
pendages on  that  side.      He  agreed  as  to  the  diagnosis,    but   after   some  dis- 


THERAPEUTIC  HINTS.  ^ 

cussion,  it  was  agreed  to  wait  until  half-past  eight  to  see  if  the  patient  would 
rally.  A  tenth  of  a  grain  of  morphia  was  given  hypodermically,  iced  cloths 
were  placed  on  the  abdomen,  hot  bottles  were  placed  to  her  feet  and  legs  and 
a  little  brandy  and  water  were  ordered.  At  half-past  eight  she  was,  if  any- 
thing, worse.  A  hypodermic  of  strychnia  was  given.  At  eleven  o'clock 
she  was  anaesthetized.  On  opening  the  abdominal  cavity,  it  was  found  to  be 
filled  with  clottled  blood  and  fluid.  The  left  Fallopian  tube  was  ruptured, 
and  contained  the  foetus  in  its  unbroken  membranes.  The  patient  died  be- 
fore the  operation  was  completed.  She  would  undoubtedly,  have  had  a 
much  better  chance  of  living  had  the  operation  been  performed  ten  hours 
sooner." 

[These  two  cases,  with  such  different  results,  exemplify  most  forcibly  the 
field  for  prompt  and  lifesaving  abdominal  surgery.  Ruptured  ectopic  gesta- 
tion is  a  clear  case  of  bleeding  from  a  torn  artery,  and  with  the  lights  of 
to-day  should  be  recognized  and  the  patient  saved.  The  diagnosis,  with  the 
picture  once  fixed  in  the  mind,  is  not  difficult.  In  most  cases  there  is  a  his- 
tory of  several  years  of  sterility,  then  a  suspicion  of  pregnancy,  in  the  early 
months  of  which  there  is  the  sudden  occurrence  of  "intense  abdominal  pain, 
followed  by  anxious  countenance,  acute  anemia  and  collape"  (Price).  If 
there  is  doubt  the  diagnosis  will  be  confirmed  on  making  the  incision  through 
the  abdominal  wall,  as  on  exposure  the  omentum  will  be  almost  black  having 
been  flooded  with  blood.  In  the  cases  I  saw  operated  on  by  Dr.  Price  this 
condition  invariably  existed,  and  furthermore,  he  impressed  upon  me  the 
fact  that  in  most  cases  coming  to  the  surgeon,  the  rupture  would  be  found 
in  the  distal  half  of  the  tube,  those  cases  in  which  it  occurred  in  the  proxi- 
mal half  generally  proving  fatal.]  H.  S.  L. 


tTberapcutic  1bint6, 


For  Facial  Erysipelas  {Medical  News): 
IJ — Ac.  carbolici,  ^ 

Tr.  iodi,  V  aa 3  i  ; 

Alcohol,  ) 

Ol.    terebinth, 3  ij ; 

Glycerini, 3  iij. 

M. — Sig:   Paint  over  affected  parts. 

Drugs  Which  May  or  May  Not  Be  Prescribed  During 
Pregnancy. — Boissard  {/oi/rnal  des  Practictens,  Aug.  28,  1897) 
states  that  drugs  having  an  ecbolic  action  are  always  to  be 
avoided  except  in  cases  of  contracted  pelvis  where  it  is  thought 


2^8  THERAPEUTIC  HINTS. 

necessary  to  interrupt  the  utero-gestation.  Quinine,  sodium 
salicylate,  narcotic,  analgesic  and  anesthetic  remedies  may  be 
employed  when  indicated  without  injury.  Mercury  finds  its 
application  in  known  specific  c^ses,  and  purgatives  during  the 
whole  course  of  pregnancy  should  be  administered  without  fear 
of  producing  untoward  or  dangerous  results. — Med,  Age. 

A  Local  An.-esthetic  for  Extraction  of  Teeth. 

]§. — Menthol gr.   i6o 

Tinct.  myrrh drops  80 

Alcohol 3  ij 

M. — Sig:  Thoroughly  dry  the  gums  and  apply  freely  for  a 
few  minutes.  Use  more  freely  for  a  permanent  than  a  decidu- 
ous tooth. — Pediatrics. 

Foreign  Bodies  in  the  Ear. — Burnett  {Philadelphia  Poly- 
clinic) in  commenting  upon  a  case  of  foreign  body  in  the  ear 
occurring  in  his  practice,  advances  the  following  practical  de- 
ductions: 

1.  Always  examine  an  ear  said  to  contain  a  foreign  body,  and 
find  out  whether  such  is  the  case  before  endeavoring  to  remove 
the  foreign  substance. 

2.  Whatever  a  child  puts  into  its  ear,  or  allows  to  be  placed 
there,  is  placed  there  easily  and  painlessly,  and  can  be  as  easily 
and  painlessly  removed  by  any  physician  who  can  properly 
syringe  the  ear. 

3.  A  foreign  substance  was  never  known  to  be  impacted  in  a 
child's  ear  by  the  child.  Neither  has  a  foreign  body  ever  been 
iTipacted  in  the  ear  by  syringing. 

4.  When  impaction  has  occurred,  or  any  injury  to  the  ear, 
after  the  insertion  of  an  inanimate  substance  by  the  child  into 
its  ear,  such  injuries  have  been  the  result  of  instrumental  en- 
deavors at  extraction  by  means  of  probes,  hooks,  forceps,  etc. 
The  latter  are  never  needed  by  anyone  at  first,  as  the  syringe 
will  suffice  in  all  cases  where  no  violence  has  been  exerted  upon 
the  ear.  Instruments  of  any  other  kind  should  never  be  em- 
ployed at  any  time  by  any  hand  but  the  most  skilled. 

5.  If  animate  bodies,  insects,  etc.,  get  into  the  ear,  a  few 
drops  of  oil  will  smother  them,  and  they   can  then  be  syringed 


NOTES    AND  ITEMS.  2?Q 

from  the  ear.  Maggots  can  be  destroyed  by  a  few  drops  of 
ether  or  chloroform  put  into  the  ear.  They  can  then  be  lifted 
out  by  means  of  forceps.  But  this  latter  act  can  be  performed 
only  by  an  expert.  However,  the  intense  pain  caused  by  the 
presence  of  maggots  in  the  ear  can  be  allayed  by  the  use  of 
chloroform  in  the  ear,  as  stated  above. — Int.  Med.  Mag. 


THE  PUBLIC  SERVICE. 


NAVY    DEPARTMENT. 

Changes  in  the  Medical  Corps  of  U.  S.  Navy  for  the  2  weeks 
ending  March  24,  1898. 

Surgeon  L.  G.  Heneberger,  detached  from  the  Maine  and 
ordered  home  to  wait  orders. 

Surgeon  S.  H.  Griffith,  detached  from  the  Museum  of  Hygiene, 
Washington,  and  ordered  to  the  Mayflower. 

Medical  Inspector  W.  S.  Dixon,  detached  from  Brooklyn  and 
ordered  at  once  to  the  hospital  at  Norfolk,  Va. ,   for  treatment. 

Medical  Inspector  P.  Fitzsimons,  detached  from  duty  as  a 
member  of  the  Board  of  Inspection  and  Survey,  Washington, 
and  ordered  to  the  Brooklyn. 

Surgeon  J.  E.  Gardner  ordered  to  the  Dolphin,  March  24. 

Passed  Assistant  Surgeon  T.  VV.  Richards  detached  from  the 
New  York  Navy  Yard  and  ordered   to    the   Machias,  March  22. 

Passed  Assistant  Surgeon  H.  R.  Pigott,  detached  from  the 
Machias,  March  22,  proceed  home  and  wait  orders. 


IRotes  anb  litems. 


Dr.  Nicholas  Senn. — It  is  said  that  was  recently  taken  to 
Galena,  in  the  care  of  the  Sheriff,  to  answer  to  the  charge  of 
contempt  of  Court.  As  his  testimony  turned  out  to  be  imma- 
terial and  it  was  shown  that  he  was  a  very  busy  man,  he  was 
excused. 

Dr.  A.  H.  McLead  has  removed  from  Hoffman  to  Aberdeen, 
N.  C. 


2  40  NOTES    AND  ITEMS 

The  New  York  Skin  and  Cancer  Hospital  is  now  in  the 
new  building  corner  of  19th  Street  and  2d  Avenue.  This  build- 
ing was  opened  March  5th  with  appropriate  ceremonies. 

Big  Ones. — A  Winston  druggist  has  exposed  in  his  window 
a  vaccination  shield.  Some  wag  inscribed  below  it  these  words : 
"Chicago  corn  plaster." 

Parasites  in  Heart  of  Dog. — Dr.  Lamb  showed  at  a  recent 
meeting  of  the  Medical  Society  of  the  District  of  Columbia, 
the  heart  of  a  dog  containing  in  the  right  ventricle  the  filaria 
immitis,  one  of  the  thread  worms.  The  specimen  was  from  New 
Orleans,  where  it  is  said  many  dogs  die  of  this  parasitic  disease. 
This  worm  is  found  mainly  in  the  right  ventricle  of  the  heart 
and  pulmonary  artery  of  the  dog;  and  in  many  parts  of  the 
world,  especially  in  China  and  Japan.  It  seems  to  destroy  the 
animal  usually  by  obstructing  the  circulation.  The  usual  symp- 
toms are  debility,  dullness,  dropsy  and  convulsions. — National 
Med.  Review. 

Mount  Sinai  Hospital. — A  new  building  to  cost  $1,000,000 
is  to  be  erected  on  a  block  of  ground  between  looth  and  loist 
streets  and  Madison  and  Fifth  Avenues.  The  cost  of  the  ground 
was  $350,000. 

Miss  Margaret  Long,  according  to  the  Woman's  Medical 
Joicrnal.,  has  just  passed  a  most  brilliant  examination  and  matric- 
ulated in  the  senior  class  of  the  medical  school  of  the  Johns 
Hopkins  University.  She  is  a  daughter  of  the  Secretary  of  the 
Navy,  and  will  practise  medicine  in  Boston. 

A  GOOD  true  story  is  told  of  a  San  Francisco  woman  and  a 
doctor  with  a  conscience.  The  doctor  performed  a  successful 
operation  for  a  rich  woman,  and  when  asked  for  his  bill,  pre- 
sented one  for  $50.  The  lady  smiled  nnd  said,  "Do  you  con- 
sider that  a  reasonable  charge  considering  my  circumstances?" 
The  doctor  replied  :  "That  is  my  charge  for  that  operation  ;  your 
circumstances  have  nothing  to  do  with  it."  The  lady  drew  a 
check  for   $500,  and  presented  it  to    him.      He  handed  it  back. 


NOTES  AND   ITEMS.  24 1 

saying:  "I  cannol  accept  this.  My  charge  for  that  operation  is 
$50."  Very  well,"  the  l£.dy  replied:  "Keep  the  check  and  put 
the  balance  to  my  credit."  Some  months  after,  she  received  a 
lengthy  itemized  bill,  upon  which  were  entered  charges  for 
treatment  of  various  kinds  rendered  to  all  sorts  of  odds  and  ends 
of  humanity,  male  and  female,  black  and  white,  who  had  been 
mended  at  her  expense.  She  was  so  delighted  at  it  that  she  im- 
mediatly  placed  another  check  for$5oo  to  her  credit  on  the  same 
terms,  and  it  is  now  being  earned  in  the  same  way. — Phil.  Aled. 
Jour. 

Queer  Vaccination. — During  the  recent  small-pox  scare  in 
a  North  Carolina  town,  a  lady  who  desired  to  be  vaccinated  ad- 
monished her  physician  to  be  sure  to  "have  some  perfectly  fresh 
uterus  to  vaccinate  her  with." 

The  chair  of  disea'-es  of  the  eye,  ear,  and  throat  at  the  Medical 
College  of  Virginia,  made  vacant  by  the  death  of  Professor 
Charles  M.  Sheilds,  will  be  filled  at  the  annual  meeting  of  the 
of  visitors  of  the  college  April  21st.  All  applications,acompan- 
ied  by  credentials,  should  be  forwarded  to  Christopher  Tomp- 
kins, M.  D,  Dean,  Richmond,  Va. 

Age  of  Parents,  and  Its  Influence  on  Their  Progeny. — 
Jarosie  has  brought  an  interesting  subject  under  the  notice  of 
the  Director  of  the  Hungaiian  Statistics  Bureau,  wherein  he 
argues,  from  24,000  carefully  investigated  cases,  that  the  off- 
springs of  a  parent  between  twenty  and  twenty-five  years  are 
likely  to  be  weak  and  feeble,  but  between  twenty-five  and  forty- 
five  years,  strong.  The  mother  has  most  robust  chldren  be- 
tween twenty-five  and  thirty-fiive.  More  healthy  children  are 
born  when  the  mother  is  ten  years  younger  than  the  father — ten 
per  cent,  more  favorable  than  when  about  the  same  age. 

On  Toothache  Remedies. — Dr.  Frederick  C.Coley.  in  an  arti- 
cle on  the  medical  treatment  of  toothache,  in  a  recent  issue  of  the 
"Practitioner,"  states  that  of  all  medical  remedies  for  tooth- 
ache he  knows  of  none  which  is  so  successful  as  salicylate  of 
sodium.  He  believes  it  is  especialy  useful  in  those  cases  when 
pain    is  started  by  "taking  cold."     Even  in  the  condition  which 


242  NOTES    AND  ITEMS. 

called  by  dentists  "periostitis,"  where  the  carious  tooth  becomes 
slightly  loosened  and  projects  beyond  its  neighbors,  and  is  ex- 
quisitely tender  when  eating  is  attemped,  he  has  often  known 
sodium  salicylate  to  be  completely  and  permanently  successful. 
A  dose  of  gr.xv.  will  usually  relieve  the  pain  very  promptly,  and 
if  this  is  repeated  every  four  hours  the  inflammation  may  en- 
tireley  subside,  leaving,  of  course,  a  carious  tooth  to  be  disposed 
of  according  to  circumstances.  The  addition  of  belladonna  is 
often  advantageous.  Fifteen  grains  of  sodium  salicylate,  with 
15  minims  of  tr.  belladona  will  often  procure  refreshing  sleep  in- 
stead of  a  night  of  agony."  Dr.  Coley  believes  that  this  use  of 
salicylate  of  sodium  is  not  generally  known.  He  first  became 
aware  of  it  by  experience  on  his  own  person,  and  since  then 
he  has  used  it  with  many  brilliant  successes  and  few  failures  in 
a  very  large  number  of  patients.  He  has  once,  however,  known 
phenacetin  to  succeed  where  salicylate  failed,  but  he  finds  the 
salicylate  is  much  more  worthy  of  confidence  as  a  rule.  It  is  espe- 
cially valuable  with  children,  where  extraction  of  teeth  is  to  be 
avoided,  if  possible,  lest  the  development  of  the  maxilla  should 
be  injured. — Inter.  Med.  Mag. 

Human  Nature  in  the  Steerage. — H.Phelps  Whitmarsh 
writes  of  "The  Steerage  of  To-day"  in  the  February"Century," 
Mr.  Whitmarsh,  who  crossed  the  ocean  in  the  steerage  himself, 
says :  To  me  the  most  noticeable  thing  about  the  life  was  the  ease 
with  which  the  yoke  of  civilization  was  thrown  off.  If  condi- 
tions be  favorable,  I  opine  that  a  large  proportion  of  the  steerage 
passengers  throw  back  to  their  Darwinian  ancestry  about  the 
third  day  out.  Away  from  home,  country  and  religious  influ- 
ences, unrestrained  by  custom  conventionality,  bound  by  no 
laws  of  action,  and  separated  from  all  that  force  of  opinion  so 
strong  in  the  world  ashore,  they  let  themselves  go,  and  allow 
their  baser  natures  to  run  riot.  No  sooner  has  the  seasickness 
left  them  than  they  growl  and  snarl  over  their  food  like  dogs, 
scrambling  for  the  choice  pieces,  and  running  off  to  their  bunks 
with  them;  they  grow  quarrelsome;  their  talk  is  lewd  and  in- 
sulting; brute  strength  is  the  ascendant;  and,  without  shame, 
both  sexes  show  the  animal  side  of  their  natures.  But  most  ap- 
parent and  obnoxious  are  the  filthy  habits  into  which  many  of 
them  fall.     The  sea  seems  to  demoralize  them.      Some  of  them 


NOTES   AND  ITEMS 

will  remain  for  days  in  their  births,  where,  without  changing 
their  clothes,  they  eat,  sleep,  and  are  sick  with  the  utmost  im- 
partiality, and  without  the  blessing  of  soap  and  water.  Hence 
the  steerage  as  a  whole,  the  "married  quarters"  (where  there 
were  children)  in  particular,  was  ill- smelling  and  otherwise  ob- 
jectionable.—  The  Sanitarian. 

Dr.  Edwin  Klebs,  now  of  the  Post-Graduate  Medical  School  of 
Chicago,  formerley  of  the  University  of  Zurich,  Switzerland, 
and  the  joint-discoverer  with  Dr.  Loefifler  of  the  bacillus  of  diph- 
theria, has  lately  examined  the  stomachs,  duodenums  and  livers 
of  two  patients  that  died  of  yellow  fever  in  Mobile.  He  sought 
for  Sannarelli's  Bacillus  icteroides  but  could  find  no  trace  of  it. 
Instead,  however,  he  found  what  he  thinks  is  a  virulent,  patho- 
genic ameba  that  he  suspects  has  something  to  do  with  the  pro- 
duction of  the  disease.  He  is  writing  for  a  fresh  supply  of  ma- 
terial on  which  to  work  before  making  a  distinct  claim  of  results 
— Am.  Afed.  Surg.  Bull. 

The  Paternal  Govern.mint  of  our  Health  Board. — The 
therapeutists  of  the  New  York  City  board  of  health  are  con- 
stantly widening  their  sphere  of  usefulness,  and  now  announce 
that  any  one  bitten  by  a  mad  dog  can  step  up  to  the  laboratory 
and  be  cured  at  the  city's  expense.  The  person  in  charge  of 
this  new  venture  has  reported  to  Colonel  Murphy  that  "the  new 
laboratory  in  the  vaccine  building  contains  every  means  for 
carrying  on  the  treatment  in  the  most  satisfactory  manner.  As 
the  treatment  reduces  the  mortality  of  those  bitten  by  rabid 
animals  from  10  per  cent,  or  more  to  less  than  i  per  cent.,  and 
as  there  is  now  no  place  where  the  very  poor  can  receive  free 
treatment,  it  is  respectfully  advised  that  the  department  of 
health  authorize  the  administration  of  this  treatment  to  those 
who  have  been  bitten  by  rabid  animals  and  who  may  present 
themselves  for  treatment."  Colonel  Murphy  has  given  the  de- 
sired authorization,  and  now  the  press  agent  of  the  department 
tells  the  newspapers  that  seven  fortunates  from  the  borough  of 
Richmond  are  at  present  under  treatment,  and  that  there  is 
every  prospect  of  their  returning  home  alive.  It  is  not  said 
whether  the  dog  that  bit  the  seven  was  mad  or  only  angry. — 
Med.   Record. 


iReaMiia  Botlces. 


Cleanliness  in  Catarrhal  Affections. — One  of  the  funda- 
mental principles  in  the  treatment  of  catarrhal  troubles  of  the 
nose  and  throat  maj''  be  summed  up  in  a  single  word  "cleanli- 
ness." To  permit  secretions  to  remain  on  the  surface  of  the  in- 
flamed mucous  membranes  is  to  increase  the  existing  irritation 
and  delay  the  healing  process.  The  retained  mucus  and  crusts 
form  a  fertile  soil  for  the  growth  of  microbes,  and,  after  under- 
going decomposition  act  as  severe  irritants.  It  follows,  there- 
fore, that  means  should  be  taken  to  remove  these  inflammatory- 
products  and  keep  the  mucous  membranes  as  clean  as  possible. 
All  rough  manipulation  should  be  avoided — the  object  is  not  to 
scrub  off  the  mucus  and  crusts  which  are  often  quite  firmly  ad- 
herent, but  to  dissolve  them  and  wash  them  away.  For  this 
purpose  an  alkaline  antiseptic  solution  such  as  Bensolyptus 
(Schieffelin)  is  especially  indicated.  Experience  has  shown  that 
an  alkaline  fluid  is  not  only  the  best  solvent  for  mucus,  but  also 
exerts  a  soothing  effect  upon  the  inflamed  mucous  membranes. 
In  Bensolyptus  these  beneficial  effects  of  the  alkaline  ingredients 
are  supplemented  by  its  antiseptic  and  anti-catarrhal  properties, 
in  consequence  of  which  it  arrests  all  growth  of  microbes  and 
facilitates  the  process  of  healing.  In  the  various  forms  of 
rhinitis,  pharyngitis  and  tonsillitis,  Bensolyptus  has  proved  an 
important  auxiliary  in  the  treatment  by  promoting  cleanliness, 
allaying  irritation  and  preventing  bacterial  infection. 

Bensolyptus  is  the  outcome  of  careful  experiments  made  in  the 
laboratory  of  Schieffelin  &  Co.,  to  produce  an  ideal  alkaline  anti- 
septic fluid  and  the  high  reputation  enjoyed  by  the  products  of 
this  firm  for  over  a  century  renders  any  further  comment  unnec- 
essary. 

Chemical  Food  is  a  mixture  of  Phosphoric  Acid  and  Phos- 
phates, the  value  of  which  Physicians  seem  to  have  lost  sight  of 
to  some  extent,  in  the  past  few  years.  The  Robinson  Pettet 
Co.,  to  whose  advertisement  we  refer  our  readers,  have  placed 
upon  the  market  a  much  improved  form  of  this  compound, 
"Robinson's  Phosphoric  Elixir. "  Its  superiority  consists  in  its 
uniform  composition  and  high  degree  of  palatability. 


SYR.  HTPOPHOS.  CO,,  FELLOWS 

Contains  the  Essential  Elements  of  the  Animal  Organization-Potask  and  Lime; 
The  Oxidising  Agents — iron  and  Maganese: 
The  Tonics — Quinine  and  Strychnine; 

And  the  Vitalizing  Constituent—Phosphorus:  the  whole  combined  in  th«  form 
of  a  Syrup  with  slightly  Alkaline  Bacteria. 

It  Differs  in  Its  Effects  from  all  Analogous  Preparations;  and  it  posses- 

ses  the  Important  properties  of  being  pleasant  to  the  taste,  easily  borne   by  the 
stomach,  and  harmless  under  prolonged  use. 

It  has  Gained  a  Wide  Reputation  particularly  in  the  treatment  of  Pnhnonary 
Tuberculosis,  Chronic  Bronchitis,  and  other  affections  of  the  respiratory  organs. 
It  has  also  been  employed  with  much  success  in  various  nervous  and  debilitatln.r 

G186£iS6S*  " 

Its  Curative  Power  Ja  largely  attributable  to   its  stimulant,  tonic,  and  nutritive 

properties,  by  means  of  which  the  energy  of  the  system  is  recruited. 
Its  Action  is  Prompt;  it  stimulates  the  appetite  and  the  digestion,  it  promotes  as- 

similation,  and  it  enters  directly  into  the  circulation  with  the  food  products. 
The  prescribed  dose  produces  a  feeling  of  buoyancy,  and  removes  depression  and  mel- 
apcholy;  hence  the  preparation  is  of  great  value  in  the  treatment  of  mental  and  ne,^n». 
*^^^^^^°'-     From  the  fact,  also,  that  it  exerts  a  double  tonic  influence,  and  induce,  a 
healthy  flow  of  the  secretions,  its  use  is  indicated  in  a  wide  range  of  diseases. 

NOTICE-CAUTION. 

The  success  of  Fellows'  Syrup  of  Hypophosphites  has  tempted  certai« 
persons  to  offer  imitations  of  it  for  sale.  Mr.  Fellows,  who  has  examined 
»amples  of  several  of  these,  finds  that  no  two  of  them  are  identical, 
md  that  all  of  them  differ  from  the  original  in  composition,  in  freedom 
rom  acid  reaction,  in  susceptibility  to  the  effects  of  oxygen  whe»  ex- 
posed to  light  or  heat,  in  the  property  of  retaining  the  strych- 
line  in  solution,  and  in  the  medicinal  effect*. 

As  these  cheap  and  inefficient  substitutes  are  frequently  dispensed  i»- 
tead  of  the  genuine  preparation,  physicians  are  earnestly  requested, 
rhen  prescribing  the  Syrup,  to  write  "Syr.  Hypophos.  Fellows." 

As  a  further  precaution,  it  is  advisable  that  the  Syrup  should  be 
rdered  ia  the  original  bottles ;  the  distinguishing  marks  which  the  bot- 
es (and  the  wrappers  surrounding  them)  bear,  can  then  be  examiiied, 
id  the  genuin^ess — or  otherwise — of  the  contents  thereby  proved. 

ICKMCAI,  UBTTJIBS  MAT  BS  ADDKBSSID  TO 

48  Vesey  Street.  New  York. 


The 

Committee  of 
Ways  and 
Means 


Is  the  most  importaiit  one  in  Congress.  The  physician, 
when  called  upon  to  treat  a  case  of  Typhoid  Fever, 
must  resolve  himself  into  a  committee  of  one  to 
devise  "ways  and  means"  to  combat  the  disease.  Nu- 
trition is  of  vital  moment. 

<^i^UM)  Nltfofer^oiis  possesses  the  following 
essential  qualities  as  a  food  : 
Pal3tabilit7. 


I  St. 
2d. 

3d. 
4th. 
5th. 
6th. 


All  the  elements  of  nutrition. 
Pre-digested  condition 
Peptogenic  potency. 
Slightly  stimulating  effect. 
Aseptic  state. 


iS  it  any  wonder,  therefore,  thai    it  is  a  favorite 
nutriment  in  Typhoid  Fever  > 


Note : — If  an  efficient  antiseptic 
remedy  is  desired  Liquid  Peptonoids 
with  Creosote  should  be  adminis- 
tered, thus  furnishing  at  the  same 
time  both  food  and  medicine. 


(»l  THI:R]M  fines,  X.  C,  is  the  Best  Heath  Resort  in  tiie 
Son  III.    Write  to  J.   T.  PATRICK  for  Inroriiiatioii. 


ifenty-Firs.    Vcar.  APRIL    20,    1898.  Vol.41       N< 

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Anti-Diphtheritic  Serum.  We  continue  to  lead 
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Samples  cheerfully  furnished  to  the  profession. 

PRICE  75c  per  ounce. 

The  Pyroctin  Company, 

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Ag^ents. 


ORTHOPEDIC   .iW"    Trusses 

CRUTCHES. 


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SURGERY. 


Vol.  XLI.  Winston,  April  20,    1898.  No.  8. 


©rioinal  Communications. 


CLINICAL  DEMONSTRATIONS  IN  OPERATIVE  GYNE- 
COLOGY. 

By  Augustin  H.   Goelet,   M.  D.,   Professor  of  Gynecology  in 
the  New  York  School  of  Clinical  Medicine,  etc. 


CONSERVATIVE    OOPHORECTOMY. 


GENTLEMEN: — The  first  operation  to-day  is  for  removal 
of  both  ovaries.  The  patient  is  29  year  old  and  has 
suffered  from  puberty  with  severe  dysmenorrhoea.  For 
the  past  four  or  five  years  she  has  suffered  not  only  during  the 
menstrual  periods  but  also  during  the  interval  with  severe 
ovarian  pain  which  has  become  gradually  worse  and  now  she  is 
a  complete  invalid.  Everything  has  been  done  for  her  relief, 
including  curettage  for  a  chronic  endometritis  which  has  ex- 
isted for  a  long  time,  but  with  only  temporary  benefit.  I  am 
convinced  that  nothing  short  of  removal  of  the  ovaries,  which 
I  believe  are  in  a  state  of  cystic  degeneration,  will  afford  per- 
manent relief.  On  account  of  the  age  of  the  patient  I  shall,  if 
possible,  do  a  conservative  operation  and  save  a  piece  of  one 
ovary  if  both  require  removal.  I  have  done  this  in  a  number 
of  instances  and  alv/ays  with  the  happiest  result.  The  patients 
have  recovered  fully  and  menstruation  has  continued  undis- 
turbed. 


246  GOELET— CONSERVATIVE  OOPHORECTOMY. 

We  will  begin  by  curetting  the  uterus  to  overcome  the  endo- 
metritis which  has  not  been  cured  by  the  curettage  done  six 
months  ago.  The  condition  is  one  of  chronic  catarrhal  inflam- 
mation, with,  as  you  see,  a  glary  mucous  discharge  and  con- 
siderable erosion  of  the  external  os  and  cervix.  I  shall  use  the 
stiff  dull  curette  within  the  cavity  and  the  sharp  curette  for  re- 
moving the  tough,  hypertrophied  granulations  about  the  inter- 
nal OS,  which  always  offer  a  barrier  to  free  drainage.  The 
sharp  curette  is  used  likewise  in  the  cervical  canal  and  upon  the 
eroded  surface  about  the  external  os.  Though  I  do  not  usually 
pack  the  uterus  with  gauze  after  curettage  in  these  cases  of 
catarrhal  endometritis,  I  shall  do  so  in  this  case  so  as  to  secure 
better  drainage  tor  the  first  48  hours,  smce  to  irrigate  the  uterus 
so  soon  after  an  abdominal  operation  would  disturb  the  patient. 
This  gauze  will  not  be  permitted  to  remain  longer  than  48  hours 
by  which  time  it  will  have  accomplished  all  that  is  required  of 
it,  and  it  would  dam  buck  the  secretion  and  irritate  if  left  longer. 
After  this  during  convalescence  the  uterus  may  be  irrigated  as 
required. 

The  abdominal  cavity  has  now  been  opened  by  a  small  incis- 
ion in  the  median  line  above  the  pubis  and  I  insert  two  fingers 
of  my  left  hand  to  explore  the  pelvis.  The  adhesions  are  few 
and  easily  broken  up  and  the  left  ovary  is  drawn  up  into  the 
incision.  You  see  it  is  in  a  bad  state  of  degeneration  and  it  will 
not  be  possible  to  save  any  portion  of  it.  The  tube  as  you  see 
is  also  enlarged  and  much  thickened  showing  an  interstitial 
salpingitis.      This  will  be  removed  also. 

Both  are  drawn  well  up  into  the  wound  so  as  to  pucker  up 
the  broad  ligament  and  form  a  pedicle.  The  broad  ligament  is 
now  transfixed  with  a  double  ligature  of  stout  silk  which  is  tied 
on  either  side,  thus  including  both  ends  of  the  ovarian  artery. 
This  is  probably  the  best  manner  of  tying  off  the  appendages  as 
it  puckers  up  the  remaining  stump  of  broad  ligament,  thus 
forming  better  support  for  the  uterus  afterwards.  The  tube 
and  ovary  are  now  excised,  the  ligature  ends  cut  short  and  the 
stump  dropped  back  into  the  pelvis.  I  prefer  silk  for  ligature, 
because  it  is  safer,  stronger  and  can  be  depended  upon  not  to 
give  way  if  tied  properly.  As  a  proof  of  this  I  have  never  had 
a  case  of  secondary  haemorrhage,  and  I  invariably  use  silk  upon 
the  ovarian  and  uterine  arteries. 


GOELET-CONSERVATIVE  OOPHORECTOMY.  247 

The  right  ovary  you  see  is  also  in  bad  condition,  but  the  tube 
is  not  thickened,  and  it  is  probably  pervious,  though  there  may 
be  some  catarrhal  inflammation  of  its  lining  membrane.  I  shall 
leave  the  tube  and  excise  the  diseased  portion  of  the  ovary.  Catch- 
ing the  ovary  between  the  middle  and  index  fingers  or  between 
the  thumb  and  index  finger,  the  vessels  supplying  it  are  compress- 
ed, and  with  a  pair  of  curved  scissors  at  least  three  quarters  of  its 
structure  is  removed.  This  has  removed  all  that  is  diseased  and 
we  may  safely  leave  the  remainder.  The  vessels  are  usually  small 
and  do  not  require  a  ligature,  the  oozing  being  controlled  by 
the  suture  employed  for  uniting  the  cut  edges.  In  this  case  I 
shall  apply  a  ligature  of  fine  cat  gut  to  one  point  which  bleeds 
racher  freely  when  the  pressure  is  relaxed.  With  a  fine  cat  gut 
or  silk  ligature  and  a  fine  curved  needle  the  two  cut  edges  are 
drawn  together  by  a  continuous  Lembert  suture  from  within 
outward  toward  the  extremity  of  the  tube.  One  of  the  fimbriae 
of  the  tube  is  caught  in  the  last  loop  of  the  suture  which  at- 
taches it  closely  to  the  remaining  ovarian  tissue. 

There  will  be  no  occasion  for  flushing  the  peritoneal  cavity 
for  it  has  not  been  soiled.  We  will  now  examine  the  stump  on 
the  other  side  to  make  sure  that  the  ligature  remains  secure. 
We  are  now  ready  to  close  the  abdominal  incision  which  is  done 
as  before  described,  viz.,  first  inserting  deep  silk  worm  gut, 
interrupted  sutures  including  the  whole  thickness  of  the  ab- 
dominal wall,  then  a  continuous  suture  of  fine  chromicized  cat 
gut  which  is  made  to  include  in  the  first  layer  the  peritoneal 
edges  and  the  muscular  layer,  and  in  the  second  layer  the 
fascia.  This  method  is  always  preferred  because  it  gives  the 
strongest  possible  cicatrix. 

PROLAPSUS     OF      THE     UTERUS     COMPLICATED      WITH    BROAD    LIGA- 
MENT   CYST. 

The  second  operation  will  be  suspension  of  the  uterus  to 
overcome  an  advanced  degree  of  procidentia  complicated  with 
a  cyst  on  the  right  side  the  size  of  a  cocoanut.  The  patient, 
who  is  35  years  old,  had  one  child  ten  years  ago,  since  which 
time  she  has  suffered  more  or  less  from  uterine  troubles.  For 
the  past  three  or  four  years  she  has  noticed  that  there  was  a 
prolapsus  which  has  been  getting   worse.      In    addition   to  this 


248  GOELET— CONSERVATR'E  OOPIIOREi^TOMY. 

she  has  during  the  past  year  suffered  more  than  usual  with 
backache  and  a  severe  dragging  pain  in  the  right  side  low  down. 
It  is  probably  this,  more  than  anything  else,  that  has  driven  her 
to  seek  aid.  Her  physician  who  referred  her  to  me  attempted 
to  hold  the  uterus  in  place  by  means  ot  a  pessary  in  the  vagina 
but  it  would  not  remain  after  she  assumed  the  erect  position 
although  the  vulva  orifice  is  not  very  much  relaxed.  The  pres- 
ence of  the  tumor  above  forces  the  uterus  down.  This  leads 
me  to  believe  it  is  a  cyst  of  the  broad  ligament  developed 
upward,  as  they  produce  more  displacement  of  the  uterus  than 
the  ordinary  ovarian  cysts  which  are  pedunculated. 

The  uterus  is  much  enlarged  and  the  cervix  is  elongated,  and 
I  will  begin  by  curetting  and  packing  with  gauze  which  I  shall 
expect  to  aid  materially  in  reducing  the  size  and  weight  of  the 
organ.  The  perineum  is  intact  and  will  therefore  need  no  atten- 
tion. The  prolapsus  of  the  vaginal  wall  will  be  overcome  when 
the  uterus  is  drawn  up  against  the  abdominal  wallas  it  is  at  first 
when  suspended. 

We  will  now  proceed  with  the  abdominal  operation.  The 
peritoneal  cavity  has  been  opened  and  you  can  see  the  cyst 
protruding  up  into  the  incision  as  the  abdomen  is  compressed. 
As  I  pass  my  hand  into  the  cavity  and  sweep  it  around  the 
tumor  I  find  there  are  no  adhesions  but  the  tumor  has  a  broad 
surface  of  attachment  confirming  my  suspicion  that  it  is  de- 
veloped between  the  folds  of  the  broad  ligament.  The  walls, 
are  as  you  see  very  thin  and  it  will  be  quite  impossible  to  enu- 
cleate it  without  rupturing  it.  I  shall,  therefore,  tap  it  as  I 
would  an  ordinary  ovarian  cyst  and  enucleate  the  sac.  The 
fluid  is  perfectly  clear,  thin  and  straw  colored. 

It  is  going  to  be  much  more  difficult  to  enucleate  this  sac  than 
that  of  the  ordinary  ovarian  tumor  which  has  a  distinct  pedicle. 
In  those  cases  the  pedicle  is  transfixed  with  a  double  ligature 
which,  being  tied  on  either  side,  permits  us  to  sever  it  on  the 
outer  side  of  the  ligature. 

In  these  cases  the  broad  ligament  must  be  split  and  separated 
until  the  base  and  attachment  of  the  cyst  is  reached.  Instead 
of  splitting  the  yeritoneum  at  the  top  of  the  cyst  which  would 
leave  considerable  redundancy  to  be  trimmed  off  afterwards,  I 
will  devide  the  peritoneal   covering  in  front  and   behind    low 


MEISENBACII-FOKETGN  I'.ODIES.  240 

down  near  the  base  of  the  cyst  sac.  I  now  peel  the  peritonem 
down  with  the  thumb  nail  drawing  the  sac  up  meanwhile.  I 
have  succeeded  in  separating  the  folds  of  the  broad  ligament 
nearly  down  to  its  base  and  have  secured  a  pedicle  which  may 
be  ligated  in  the  usual  manner,  and  divided  to  the  outer  side  of 
the  ligature. 

The  intestines  being  held  back  you  can  see  how  nicely  the 
edges  of  the  broad  ligament  fall  together.  I  will  unite  them  by 
a  running  suture  of  fine  cat  gut,  burring  the  stump  between 
the  folds  of  the  broad  ligament.  Should  drainage  become 
necessary  subsequently  it  is  obtained  by  puncturing  the  vaginal 
roof  up  into  the  broad  ligament. 

I  will  now  proceed  to  attach  the  uterus  to  the  anterior  abdom- 
inal wall.  Seizing  the  fundus  with  a  pair  of  angular  tenaculum 
forceps  it  is  drawn  up  into  the  abdominal  wound.  Three  sus- 
taining sutures  are  used  in  this  case  inserted  through  the  peri- 
toneum and  subperitoneal  fascia  of  the  abdominal  wall  on  each 
side  near  the  lower  angle  of  the  abdominal  incision  and  upon 
the  posterior  aspect  of  the  fundus  about  an  eighth  of  an  inch 
apart.  These  sutures  are  of  medium  size  silk  and  they  are  tied 
within  the  peritoneal  cavity,  being  closed  within  this  cavity 
when  the  peritoneal  margins  of  the  abdominal  incision  are 
united  over  them.  The  deep  silk  worm  gut  sutures  at  the  lower 
angle  of  the  wound  are  inserted  so  as  to  secure  the  peritoneum 
near  the  attachment  sutures,  and  prevent  too  early  sagging  of 
the  uterus  away  from  the  abdominal  wall. 

In  other  respects  the  abdominal  wound  is  closed   as  was  done 

in  the  first  operation  to-day. 

Note.— Both  of  these  patients  made  an  excellent  recovery,  and  the  results 
have  been  all  that  was  anticipated. 


GASTROTOMY  FOR  REMOVAL  OF  FOREIGN  BODIES. 
Abstract  of  a  paper  by  Dr.  A.  H.  Meisenbach,  St.  Louis,  Mo. 


THE  author  presents  in  the  Journal  of  the  American  Medical 
Association  the  report  of  a  case  recently  subjected  to  op- 
eration  in   St.    Louis  which    pertinently    illustrates    the 
verity  of  the  old  truism  as  to  the  fact  of  truth's  being  stranger 


250  MEISENBACH— FOETIGN  BODIES. 

than  fiction.  Along  with  a  carefully  detailed  report  of  his  case 
the  doctor  gives  a  valuable  review  of  similar  cases  reported  up 
to  date. 

His  patient  aged  22,  had  for  nine  years  previous  given  fre- 
quent exhibitions  as  a  professional  sword  swallower.  Along 
with  this  feat  he  combined  other  deglutatory  attainments  which 
won  for  him  the  title  of  "The  Human  Ostrich."  Nails,  screws, 
pearl  top  lamp  chimneys,  fence  staples,  etc.,  were  among  the 
articles  with  which  he  was  wont  to  entertain  his  audiences. 

Coming  for  treatment  he  stated  to  the  doctor,  that  up  to 
1897  he  experienced  no  inconveniences  from  his  practices.  In 
March  of  that  year  he  began  to  have  pains  in  his  stomach  and 
he  noticed  for  the  first  time  a  lump  in  his  stomach.  On  March 
30,  he  was  admitted  to  the  Rebekah  Hospital  and  a  most  scru- 
tinizing examination  made. 

The  physical  examination  alone  was  sufficient  to  establish  the 
diagnosis  of  ff»reign  bodies  in  the  stomach.  The  patient  was 
willing  to  have  an  opeiation  performed,  and  so  was  admitted  at 
once  (March  30)  to  the  Rebekah  Hospital  for  observation  and 
preparation  for  the  operation.  He  was  placed  on  liquid  diet 
and  orders  left  to  look  after  the  bowels  and  stools. 

The  question  whether  the  foreign  bodies  were  located  in  the 
stomach  or  elsewhere  was  a  very  important  one  from  an  opera- 
tive and  prognostic  standpoint.  That  they  were  in  the  stomach 
was  demonstated  to  my  mind  by  the  constancy  of  the  position 
of  the  mass  and  the  position  that  it  occupied.  The  previous 
history  of  the  patient  was  also  a  valuable  point  in  determining 
this.      The  points  on  which  this  diagnosis  was  based  were: 

I,  the  position  of  the  mass  when  the  patient  was  placed  in 
the  upright  position  ;  2,  the  position  of  the  mass  when  the  patient 
was  reclining  on  his  back;  3,  the  position  of  the  mass  when  the 
patient  was  reclining  on  his  right  or  left  side;  4,  the  previous 
history  of  the  patient. 

I.  The  position  of  the  mass  when  the  patient  was  on  his  feet 
or  lying  on  his  back.  Palpation  and  percussion  deraonstrated 
that  it  was  mostly  in  the  umbilical,  but  partly  in  the  lumbar 
region.  The  mass  being  a  large  one  and  composed,  as  it  was, 
of  heavy  objects,  the  raison  d'etre  naturally  would  be  that  such 
a  mass  would  in  time  have  its  effect  on    the   stomach    and    pro- 


MEISENBABH-FOREIGN  BODIES.  25  I 

duce  dilatation  of  that  part  with  which  it  was  in  contact;  grav- 
itating toward  the  lowest  point,  this  being  sonrie  part  of  the 
greater  curvature.  Gravitation  and  dilatation  would  explain 
its  position  in  these  regions.  The  only  other  position  that  the 
mass  might  have  occupied  would  be  in  some  part  of  the  large 
or  small  intestine.  But  this  supposition  becomes  untenable 
when  we  critically  analyze  the  possibilities.  If  the  mass  had 
accumulated  in  the  small  bowel  there  would  have  been  symp- 
toms of  obstruction  and  previous  history  of  pain,  possibly  in- 
flammation. Also,  the  tumor  would  not  have  been  as  constant 
in  position  unless  surrounded  by  inflammatory  adhesions  that 
would  make  a  solid,  immovable  mass.  The  same  would  be  true 
of  the  colon  ;  if  in  the  cecum,  we  would  certainly  have  had  a 
train  of  symptoms  of  either  obstruction  or  inflammation;  if  in 
the  transverse  colon,  the  position  would  have  been  lower.  The 
only  other  part  of  the  colon  would  have  been  the  sigmoid  or 
rectum,  in  either  of  which  the  symptoms  of  obstruction  or  in- 
flammatory reaction  would  have  been  prominent. 

2  and  3.  Position  of  mass  when  patient  reclined  on  right  or 
left  side  and  return  to  the  median  line  when  the  patient  was  on 
his  back  was  a  strong  argument  in  favor  of  its  location  in  the 
sto-nach.  No  other  location  could  explain  the  constancy  of 
position  in  either  region  when  the  patient  lay  on  either  side. 

4.  Previous  history  of  the  patient.  In  establishing  a  diag- 
nosis this  is  of  the  utmost  importance.  Such  a  mass  accumulated 
anywhere  else  in  the  gastro  intestinal  tract  would  very  soon 
have  given  rise  to  very  serious  symptoms,  either  of  inflamma- 
tion or  obstruction. 

Valuable  confirmatory  testimony  v;as  brought  out  by  the 
X-ray  experiments. 

On  April  7th  the  patient  was  submitted  to  celiotomy  by  a 
median  incision.  The  stomach  was  laid  open  two  inches  in 
length,  which  was  subsequently  enlarged  to  four  and  a  half 
inches.  A  large  mass  of  miscellaneous  hardware  now  came  in 
view  and  was  removed  partly  by  a  pair  of  Bergmann  calculus 
forceps,  partly  by  the  operator's  hand. 

The  stomach  wound  was  closed  by  three  rows  of  sutures. 
The  first  was  a  strong  No.  6  silk,  threaded  on  a  straight  thick 
darning  needle,  and  was  passed  through  the  mucosa  in  the  form 


21-2  MEISENBACH-FOREIGN  BODIES. 

of  a  continuous  suture.  The  second  was  of  the  same  silk  as 
the  former,  a  continuous  suture,  and  introduced  through  the 
peritoneum  and  muscular  coat,  so  as  to  bring  the  peritoneal 
surfaces  into  apposition.  The  beginning  of  this  line  of  sutures 
was  one-fourth  of  an  inch  from  the  end  of  the  wound,  in  the 
form  of  a  Lembert  stitch.  The  first  stitch  being  tied,  the  rest 
of  the  suture  was  passed,  entering  a  little  more  than  one-eighth 
of  an  inch  from  the  lip  of  the  wound,  coming  out  of  the  wound 
and  re-entering  the  opposite  lip  of  the  wound.  The  third  row 
was  made  with  No.  2  braided  silk  threaded  on  a  straight  No.  8 
sewing  needle.      This  was  a  continuous  layer  of  sutures. 

The  stomach  was  carefully  wiped  off  with  gauze  sponges,  as 
was  also  the  abdominal  wound.  The  packing  of  gauze,  which 
was  hardly  soiled  so  carefully  had  the  operation  been  done,  was 
removed  from  the  abdominal  wound,  everything  again  "re- 
viewed," and  then  the  stomach  was  dropped  into  the  abdom- 
inal cavity.  There  was  a  strong  temptation  to  lessen  the  size 
of  the  stomach  by  imbricating  a  portion  of  the  wall,  but  I  con- 
cluded to  allow  nature  to  assert  herself  and  correct  the  dilata- 
tion. 

The  abdominal  wound  was  closed  by  interrupted  through  and 
through  sutures.  Iodoform  collodion  was  applied  over  the  ab- 
dominal sutures,  and  a  cotton  pad  and  a  bandage  applied. 

The  time  of  operation  was  one  hour.  The  list  of  articles 
removed  from  the  stomach  shows:  Twenty-five  staples  for 
barbed  fence  wire;  15  one  and  one-half  inch  screws;  6  two  inch 
horseshoe  nails;  16  two  inch  wire  nails;  30  one  and  one-half 
inch  wire  nails;  16  thirty-two  caliber  cartridges;  5  thirty-eight 
caliber  cartridges;  2  pocket-knife  blades  (broken);  2  inches  of 
brass  wash-stand  chain,  and  2  small  staples;  total  T19  pieces. 
Eight  cartridges  passed  after  operation.  There  was  also  one 
ounce  of  comminuted  glass  (electric  light  globe) ;  making  the 
total  number  of  objects  127,  total  weight,  one  pound. 

With  the  exceptions  of  hypostatic  pneumonia  which  developed 
on  the  fourth  day  following  the  operation,  and  from  a  slight 
omental  protrusion,  the  progress  of  the  case  was  without  special 
incident.  From  both  the  complications  the  patient  haply  re- 
covered and  was  discharged  cured  on  May  ist.  Much  interest- 
ing discussion  ensued  during  the  progress  of  the  case  among 
the  hospital  staff  as  to  the  influence  of  the  X-ray  in  the  possible 


MEISEXBACII-FOREIGN  BODIES.  2  C  •? 

production  of  the  hypostatic  pneumonia.  The  general  con- 
sensus of  opinion  being  that  the  ray  was  the  cause  of  the  dis- 
ease. 

Points  of  special  interest  in  the  case  were  the  period  of  time 
over  which  the  swallowing  of  the  foreign  bodies  was  continued, 
the  large  number  of  them  found  in  the  stomach,  their  character 
and  the  absence  of  symptoms  of  irritation. 

From  the  very  carefully  prepared  table  submitted  by  Dr. 
Meisenbach  in  connection  with  his  clinical  report,  it  is  note- 
worthy that  from  the  first  gastrotomy  in  1602  foi  the  removal 
of  foreign  bodies  to  1887,  a  period  of  285  years,  only  35  cases 
have  been  recorded.  From  1887  to  1898,  22  cases  have  been 
recorded.  Summarizing  all  cases  reported  to  1898  we  have  the 
iollowing: 

Total  number  of  cases  reported  to  date,  58.  Of  this  number 
there  were  forty-seven  recoveries  or  81.03  P^i"  cent,;  ten  deaths 
or  17.24  per  cent.,  and  one  doubtful,  or  1.73  per  cent. 

Of  those  cases  in  which  no  adhesions  of  the  stomach  to  the 
abdominal  walls  or  surrounding  viscera  were  present,  thirty- 
eight  in  all,  there  were  thirty  recoveries,  or  78.95  percent.; 
seven  deaths  or  18.42  per  cent.  ;  one  doubtful  or  2.63  per  cent. 

Of  those  cases  in  which  adhesions  were  present,  thirteen  in 
all,  there  were  eleven  recoveries,  or  84.62  per  cent.;  two  death, 
or  15.38  per  cent.  Of  those  cases  in  which  the  existence  of  ad- 
hesions was  doubtful,  seven  in  all,  there  were  six  recoveries  or 
85.72  percent.,  one  death  or  14.28  per  cent.  It  will  thus  be 
seen  that  the  existence  or  absence  of  adhesions  had,  apparently 
at  least,  no  influence  on  the  mortality  rate. 

Assuming  that  the  period  of  antiseptic  surgery  began  with 
the  year  1880,  and  dividing  the  reported  cases  into  two  groups, 
i.e.,  those  reported  before  1880,  and  those  reported  since  that 
date,  we  have  the  following  exhibit  of  mortality  percentages. 
I.  Before  the  introduction  of  antiseptics:  Total  number  of 
cases  eighteen;  recoveries  fifteen  or  83.33  per  cent. ;  deaths  three 
or  16.66  per  cent.  2.  After  the  introduction  of  antiseptics; 
Total  number  of  cases  forty;  recoveries  thirty-two  or  80  per 
cent.  ;  deaths  seven  or  17.50  per  cent.  ;  doubtful  result  one  or 
2.50  per  cent. 

A  noteworthy  fact  in  connection  with  the  cases  enumerated  in 


2r^  MATTIlEWS-RECTl.'rSI  SURGERY. 

the  table  is  the  short  period  intervening  between  the  entrance 
into  the  stomach  of  the  foreign  body  or  the  diagnosis  of  its 
presence  there,  and  the  performance  of  the  operation,  during 
the  period  since  the  introduction  of  antisepsis.  This  is  prob- 
ably attributable  to  two  lactors:  i.  The  improved  methods 
and  facilities  for  making  diagnoses;  and  2,  the  improvement  in 
surgical  technique  and  the  extension  of  surgical  interference 
since  the  introduction  of  antisep;ics.  Taking  into  considera- 
tion all  the  cases  contained  in  the  table,  however,  we  find  that 
the  time  intervening  between  the  introduction  of  the  foreign 
body  into  the  stomach  and  its  removal,  is  definitely  known  in 
only  so  few  cases,  that  its  consideration  as  a  factor  of  possible 
influence  on  the  mortality  rate  would  be  entirely  unsatisfactory. 
It  has,  therefore,  not  been  considered  separately. 

The  following  is  a  summary  ot  the  foreign  bodies  removed 
from  the  stomach  by  operation: 

Forks  in  thirteen  cases;  hairballs  in  seven;  knives  in  six; 
plates  with  teeth  in  six;  spoons  in  five;  pieces  of  wood  in  four; 
pieces  of  metal  wire  in  four;  nails  in  four;  buttons  in  three; 
needles  in  three;  tooth  brushes  in  two ;  safety-pin  in  two;  peach- 
stones  in  two;  and  screws,  bar  of  lead,  piece  of  earthen  ware, 
tracheal  catheter,  metal  probang,  part  of  sword-blade,  clay-pipe 
stem,  razor,  pocket-knives,  hair-pins,  pieces  of  glass,  keys, 
window  latch,  piece  of  graphite,  and  tacks  in  one  case  each. 

J.  H.  W. 


Selccteb  ipapers. 


THE  PRESENT  STATUS  OF  RECTAL  SURGERY.* 
By  J.  M.  Matthews,  M.D.,  Louisville,  Ky. 


PLEASE  permit  me  to  thank  you  for  the  courtesy  extended 
me  in    the    invitation    co   read  a  paper  before  this  distin- 
guished society.      At  the  suggestion  of  my  friend,  Doctor 
Foster,    I  have  selected  as  my  subject  something  in  the   line  of 

*Read   before   the  Allegheny   County  Medical   Society,   Pittsburg,  Pa.,  Jan- 
uary 25,  189S. 


MATTnEWS-IlECTmr  SURGERY.  2:55 

thought  with  what  has  been  my  daily  work  for  twenty  years. 
Therefore,  with  your  permission  I  will  occupy  the  time  allotted 
me  in  considering  The  Present  Status  of  Rectal  Surgery. 

Of  course  this  paper  can  be  only  a  brief  epitome  of  the  more 
salient  points  of  the  subject,  and  in  the  consideration  of  the  same 
I  shall  try  to  avoid  discussion,  but  rather  give  my  own  views, 
which  may  be  at  variance  with  others  who  have  written  on  the 
subject. 

Time  was  when  intelligent  rectal  literature  was  very  scarce, 
for  the  reason  that  very  little  attention  was  accorded  it  by  the 
respectable  part  of  our  profession.  Hence  ic  was  but  natural 
that  diseases  of  the  rectum  were  treated  mainly  by  the  charlatan. 
Literature  from  such  a  source  would  be  both  incomplete  and 
untrustworthy.  In  the  last  decade  or  two,  however,  much  atten- 
tion has  been  given  this  subject  both  in  Europe  and  in  this  coun- 
try, and  to-day  the  status  of  rectal  surgery  is  very  different  from 
what  it  was  twenty  years  a  go. 

Across  the  water  we  are  to  thank  for  this  elucidation  such  men 
as  Allingham,  sr.  and  jr.,  Cripps,  Edwards,  Cooper,  Goodsall, 
and  Ball;  in  this  country,  Earle,  Bacon,  Martin, Cook,  Straus, 
Tuttle  Kelsey,  Lange,  Matas,  Grant,  Beach,  and  others.  To- 
day, therefore,  these  diseases  are  receiving  rational  treatment 
from  a  scientific  standpoint. 

Whereas  in  the  past  the  consideration  of  this  part  of  the  anat- 
omy included  only  such  diseases  as  piles  and  fistulae,  to-day  we 
intelligently  cope  with  cancer,  stricture,  syphilis,  tumors  of  what- 
ever nature,  and  the  terrors  of  the  same  are  greatly  reduced. 

The  person  who  considers  that  only  slight  diseases  are  within 
the  range  of  this  special  field  must  be  advised  of  the  resection  of 
the  rectum  by  Kraske's  operation,  of  anastomosing  the  colon  to 
the  rectum,  of  the  resection  of  strictures,  of  the  two  colostomies, 
and  other  major  operations  pertaining  to  this   special  surgery. 

The  writer  begs  pardon  for  a  little  personal  pride  in  that  it  has 
been  just  twenty  years  since  he  embarked  in  this  special  study 
and  urged  upon  his  professional  brethren  the  importance  of  the 
work.  How  much  of  this  great  advance  from  a  neglected  and  a 
somewhat  obscure  subject  to  its  present  prominent  position  in 
the  scientific  world  is  due  to  his  efforts,  he  would  beg  to  submit 
to  his  brethren.      He  is  fully  repaid  if  he  has  been  the  means  of 


2^6  MATTHEWS— RECTUM  SURGERY. 

encouraging  the  thought  in  others  to  accomplish  what  they  have 
in  this  line,  for  beside  their  work  he  considers  his  own  insignifi- 
cant. 

In  order  that  some  practical  points  may  be  embraced  in  this 
paper,  I  will  take  the  liberty  of  giving  some  consideration  to  most 
of  the  important  diseases  of  the  rectum  which  require  surgical 
treatment.  First  in  the  list,  in  a  practical  way,  should  be  Hetn- 
orrhoids. 

The  writer  will  be  excused  from  discussing  the/d^///^?//?/^  treat- 
ment of  any  of  these  rectal  affections,  first  because  the  time 
given  would  not  permit  of  it,  and  secondly  for  the  reason  that  he 
can  scarcely  recall  a  single  rectal  affection  which  calls  ior pal- 
liative treatment.  To  the  contrary,  he  believes  that  all  of  them 
should  be  treated  surgically. 

Referring  to  hemorrhoids,  it  is  best  to  give  but  two  divisions, 
viz.,  exUrnal  Sind  infvrnal.  The  external  variety,  of  course,  is 
formed  outside  the  sphincter  muscle.  It  may  appear  superfluous 
to  so  state,  but  I  do  it  purposely,  for  the  reason  that  in  many, 
very  many  cases  of  inflamed  external  piles  it  is  the  common 
practice  with  physicians  to  try  to  place  them  by  force  in  the 
rectum.  I  do  not  say  back  in  the  rectum,  for  they  did  not  have 
their  origin  in  the  rectum,  never  were  there,  and  no  effori  of 
course  should  be  made  to  push  them  in.  Of  whatever  kind  (ex- 
ternal) or  whatever  size,  they  should  be  allowed  to  rQ.mai\n  outside 
the  sphincter  muscle. 

Suppose,  therefore,  a  case  of  this  kind  is  under  observation, 
what  shall  be  the  treatment?  Mr.  Erecsen  said,  "All  external 
piles  should  be  cut  off."  No  better  injunction  can  be  given 
now.  You  will  permit  me  to  call  attention  to  the  difference  be- 
tween cutting  an  external  pile  0/  and  "letting  out  the  clot  of 
blood  described  by  most  authors.  The  latter  plan  in  my  opinion 
should  never  be  indulged  in;  far  better  leave  nature  to  reabsorb 
the  clot  than  to  add  to  the  inflammatory  process  by  doing  a  half 
job.      All  external  piles  should  be  cutoff." 

Internal  hemorrhoids  is  a  much  more  serious  condition.  In  a 
matter  of  diagnosis  I  desire  to  say  what  may  appear  to  you  to  be 
a  very  contradictory  statement  in  so  far  as  authors  are  concerned, 
viz,  every  disease  or  pathological  condition  in  the  rectum  can  be 
detected  with  the  finger,  except  one — internal  piles  in  a  quiescent 


MATTHEWS-REC'TUM  SURGERY.  257 

State.  I  say  this  is  in  contradiction  to  the  authorities  who  direct 
that  a  digital  examination  be  made  in  order  to  detect  piles,  and 
that  the  speculum  be  used  in  detecting  any  special  or  all  man- 
ner of  disease  in  the  rectum. 

What  shall  be  done  with  internal  piles?  It  would  not  be  dog- 
matic to  say  that  there  is  but  one  thing  to  do — operate — for  no 
local  application,  as  ointments,  etc.,  ever  cured  an  internal  pile. 
Should  internal  hemorrhoids  be  operated  on  in  the  inflamed 
state?  By  all  means,  for  thereby  you  stop  the  inflammatory 
process  and  remove  the  inflammatory  deposit,  at  the  same  time 
cure  the  patient  of  the  disease. 

What  is  the  best  operation  for  internal  piles?  In  the  experi- 
ence of  the  writer,  covering  twenty  years  and  several  thousand 
operations,  he  unhesitatingly  says  that  the  ligature  is  the  safest 
of  all  methods.  Next  to  this  plan,  of  course,  is  the  clamp  and 
cautery.  The  injection  of  acids,  etc.,  into  the  pile  tumor  is 
dangerous,  unsurgical,  and  not  attended  by  radical  results. 

Fistulain  Ano.  Fistula  in  ano  should  receive  more  serious  con- 
sideration from  the  profession  than  it  does.  A  more  destructive 
local  condition  can  hardly  be  imagined.  Beginning,  as  it  always 
does,  with  an  abscess,  it  is  fraught  from  its  start  with  danger, 
both  constitutional  and  local.  If  physicians  would  bear  this  in 
mind  and  at  the  very  incipiency  of  the  trouble  establish  free  drain- 
age, the  comparative  number  of  cases  of  fistulae  would  be  greatly 
reduced. 

I  have  taken  occasion  to  dissent  from  the  division  of  fistula  in 
ano  as  given  nearly  universally  by  authors.  It  is  of  very  little 
significance  to  say  that  a  fistula  is  an  external  or  an  internal  one, 
and  it  is  simplified  not  at  all  to  add  that  the  sinus  may  be  com- 
plete. What  is  of  much  more  purport  is  to  indicate  whether  the 
condition  is  going  to  do  little  or  much  harm.  The  writer  has 
therefore  divided  these  fistulae  into  progressive  and  non-pro- 
gressive types.  It  will  be  observed  that  there  is  a  class  of  fistulae 
which  is  limited  to  a  narrow  channel,  said  channel  being  lined 
by  a  tough  cartilaginous  membrane  miscalled  pyogenic,  which 
can  be  lefc  for  an  indefinite  time  because  non-progressive ;another 
class,  where  the  pus  formation  and  disintergration  of  tissue  are 
very  rapid,  which  should  be  c^W^A progressive,  and  which  demand 
immediate  attention.     To  the  ravages  of  this  latter  class  I  have 


2^8  MATTHEWS-RECTUM  SURGERY. 

often  seen  one  or  both  buttocks  destroyed,  the  perineum  involved, 
and  the  peritoneal  cavity  encroachod  upon.  Patients  sufferiug 
from  this  condition  often  die  from  a  slow  or  rapid  sepsis. 

In  a  matter  of  diagnosis  authors  lay  great  stress  upon  the  mat- 
ter of  finding  the  internal  opening  of  a  fistulous  track.  How 
very  unnecessary  this  injunction  is  can  be  estimated  when  it  is 
affirmed  that  if  an  external  fistula  exists,  it  calls  for  an  operation, 
and  that  during  said  operation  the  internal  opening,  if  any,  will 
be  discovered.  And  yet  I  have  known  surgeons  to  refuse  to 
operate  because  the  internal  opening  could  not  be  detected. 

As  to  the  cure  of  fistula  in  ano,  it  must  be  positively  asserted 
that  it  is  a  surgical  disease  and  must  be  cured  by  surgical  means. 
The  text  books  on  surgery  very  inadequately  describe  the  opera- 
tion. Copyirg  from  one  verbatim^  the  directions  are  as  follows: 
"Insert  a  grooved  director  into  the  external  opening,  push  it 
into  the  bowel,  catch  the  distal  end  on  the  finger,  pull  it  out  of 
the  anus,  and  then  divide  all  the  tissues  remaining  on  director." 

Such  a  procedure  would  not  cure  one  in  fifty  cases.  Each 
individual  sinus  must  be  traced  and  freely  divided,  the  bottom 
of  all  channels  freely  cut  through  or  curetted,  and  the  edges 
trimmed  closely.  Occasionally  we  find  cases  in  which  union  by 
first  intention  can  be  secured  by  bringing  the  edges  together, 
but  these  are  the  exceptions.  Allingham  once  said  to  me  that 
it  required  more  dexterity  and  delicate  surgery  to  cure  a  compli- 
cated case  of  fistula  in  ano  than  any  condition  that  he  knew  of. 
I  quite  agree  with  him. 

Prolapse  of  the  Rectum.  In  regard  to  prolapse  of  the  rectum, 
the  writer  desires  to  say  that  he  »-egards  it  as  a  very  infrequent 
condition  in  the  adult.  Twelve  cases  will  cover  all  that  he  has 
seen  in  twenty  years'  experience.  In  the  infant,  for  anatomical 
reasons,  it  is  much  more  frequently  met  with. 

In  the  adult  it  always  calls  for  surgical  treatment.  The  meth- 
ods proposed  have  proven  very  unsuccessful.  The  linear  lines 
drawn  by  the  thermo-cautery,suggested  by  VanBuren,arevery  in- 
efficient. The  taking  out  of  elliptical  pieces  and  suturing  the  edges 
is  a  slow  and  not  very  effective  operation.  The  application  of 
acids  to  the  surface  of  mucous  membrane  is  unsurgical  and  should 
not  be  thought  of.  The  writer  has  proposed  and  practiced  a  free 
circular  incision  around  anus,  and  drawing  down  the  prolapsed 


MATTHEWS-RECTUM   SURGERY.  2  eg 

membrane,  which  is  superfluous,  and  removing  it  and  then  stitch- 
ing membrane  to  the  true  skin. 

Pruritus  Ani.  It  would  appear  at  first  thought  that  pruritus 
was  an  affection  to  be  treated  medically  and  not  surgically.  But 
I  am  sure  that  every  physician  here  has  been  convinced  of  the 
futility  of  such  methods.  In  all  cases,  especially  of  long  standing, 
where  the  so-called  "scarf  skin"  has  formed,  the  most  efficacious 
plan  will  be  found  to  be  a  thorough  application  of  the  thermo- 
cautery, under  chloroform,  or  what  is  better,  a  clean  dissection 
of  all  the  skin  involved. 

Fissue  of  the  Rectum.  Fissure  of  the  rectum  I  believe  to  be  a 
misnomer,  because  it  is  impossible  for  the  pouch  of  the  rectum  to 
become  fissued,  as  is  intimated  by  the  use  of  the  term.  Fissure 
of  the  anus  is  a  much  more  appropriate  term. 

This  affection,  too,  I  believe,  should  call  for  surgical  and  not 
palliative  treatment.  It  is  so  simple  of  cure  by  gentle  divulsion 
of  the  sphincter  muscle  that  it  looks  cruel  to  subject  a  patient  to 
many  weeks  ot  treatment  by  burning  local  applications.  If  the 
physician  is  averse  to  giving  an  anesthetic  for  this  purpose,  let 
him  practice  moderate  stretching  several  times  with  a  small  di- 
vulsor,  and  a  rapid  cure  will  be  affected  in  the  greatest  number 
of  cases. 

A  distinction  should  be  drawn  between  a  fissure  of  the  anus  and 
an  irritable  ulcer  of  the  rectum  or  anus.  For  the  latter,  free  and 
rapid  divulsion  with  thorough  curettement  should  be  the  treat- 
ment. 

Ulceration  of  the  Rcctuvi.  The  writer  desires  most  emphatically 
to  dissent  from  the  view  that  benign  ulceration  of  the  rectum  is 
of  frequent  occurrence.  To  the  contrary,  he  is  on  record  as  be- 
lieving that  it  is  one  of  the  rarest  conditions  found  in  this  portion 
of  the  gut. 

I  would  respectfully  ask,  especially  of  those  who  have  given 
much  study  and  observation  to  diseased  conditions  of  mucous 
membrane  any  where,  if  it  is  not  a  rare  thing  to  notice  an  innocent 
ulceration  of  the  same?  If,  on  the  other  hand,  a  well-defined 
ulcer  is  observed  with  elevated  edges  and  a  hardened  base,  is  it 
not  invariably  suspicioned  as  being  of  constitutional  origin? 
Therefore,  I  would  beg  to  say  if  such  condition  is  found  in  the 


2  6o  MATTIIEVVS-RECTU.M   SURGERY. 

rectum,  the  question  of  an  innocent  origin   is  at  once  dissipated 
and  the  cause  sought  from  conditions  much  more  serious. 

Among  the  list  of  such  causes  are  syphilis,  cancer,and  tuber- 
culosis. Valuable  time  indeed  would  be  lost  if  such  diagnosis 
were  neglected.  In  order  then  to  present  succinctly  my  subject, 
I  will  take  this  proposition  as  granted.  How  shall  we  deal  with 
ulcerations  the  result  of  these  separate  causes?  i.  Tuberculosis. 
2.  Syphilis.      3.  Cancer. 

I.  Tubercular.  It  is  now  a  well-recognized  pathological  fact 
that  tuberculosis  may  select  any  tissue  for  invasion.  A  local 
lesion  early  recognized,  diagnosed,  and  properly  treated  will 
oftentimes  save  the  patient  from  general  tuberculosis.  The 
rectum  is  a  favorite  seat  for  such  deposit.  Its  nature  is  so  insid- 
ious that  it  is  seldom  detected  early,  and  if  seen  is  taken  for  some- 
thing less  serious.  Being  local  in  character,  it  precedes  any 
constitutional  symptoms, hence  is  easily  overlooked.  The  micro- 
scope is  of  much  diagnostic  aid  in  the  affection. 

When  a  diagnosis  is  once  made,  there  should  be  no  hesitancy 
in  applying  the  proper  treatment.  Local  remedies  are  perfectly 
//// in  their  effect,  and  such  methods  are  but  temporizing  with 
the  disease.  It  should  be  recognized  that  only  surgical  means 
will  avail  any  thing.  The  curette  and  knife  are  the  only  reme- 
dies to  be  thought  of.  The  idea,  of  course,  is  to  get  rid  of  the 
diseased,  infectious  tissue.  The  same  rule  that  is  observed  in 
removing  a  malignant  growth  should  be  practiced  in  operating 
for  a  tuberculous  ulcer,  viz,  excise  all  the  affected  tissue.  For 
this  retson  I  much  prefer  the  knife.  The  curette  is  a  most  ex- 
cellf^nt  adjuvant  to  the  knife,  but  when  used  alone  is  ineffectual. 
Indeed  the  actual  cautery  will  be  found  of  greater  service  in 
eradicating  this  diseased  structure  than  the  curette.  2.  Syph- 
ilitic. The  writer  is  on  record  as  believing  that  sixty  per  cent, 
of  strictures  of  the  rectum  are  caused  by  syphilis.  This  is  the 
percentage  claimed  by  him,  and  so  published  ten  years  ago.  He 
has  no  reason  to-day  to  retract  the  assertion.  He  is  glad  co  record 
the  fact  hat  he  has  been  in  receipt  of  many  letters  from  prom- 
inent men  in  the  profession,  both  in  this  country  and  in  Europe, 
affirming  the  proposition. 

This  was  stated  with  some  emphasis  at  a  time  when  syphilis — 
secondary — was  regarded  as  a  small  factor,  or  no  factor  at  all,  in 


MATTHEWS-RECTUM  SUKGERY.  26 1 

causing  ulceration  and  stricture  of  the  rectum.  He  can  recall 
the  time  when  most  eminent  writers  thought  that  the  only  man- 
ner in  which  syphilis  could  play  a  part  in  producing  ulceration 
of  the  rectum  was  by  the  extension  of  chancrous  pus.  Instead 
of  accepting  this  theory,  the  writer  has  often  asserted  that  chan- 
crous pus  can  in  no  manner  produce  syphilitic  ulceration  of  the 
rectum.  To  the  contrary,  it  is  by  secondary  deposit  alone  that 
syphilis  manifests  itself  in  the  rectum, and  upon  this  theory  only 
can  a  proper  treatment  be  afforded. 

I  know  that  I  will  be  pardoned  here  if  I  offer  ar  explanation 
of  certain  quotations  of  a  distinguished  friend  of  mine  in  the 
East,  who  persists  in  saying  that  I  affirm  that  ninety-nine  per 
cent,  of  the  cases  of  strictrue  of  the  rectum  are  caused  by  syphilis. 
In  the  writer's  book  on  Diseases  of  the  Rectum,  Anus  and 
Sigmoid  Flexure  will  be  founc  these  words :  "If  a  case  presented, 
and  after  a  thorough  examination  it  could  be  affirmed  that  it 
was  not  cancer^  in  ninety-nine  cases  out  of  one  hundred  it  would 
prove  to  be  syphilis."  In  explanation  it  is  argued  that  syphilis 
and  cancer  are  so  akin  in  symptoms,  both  clinical  and  general, 
that  it  is  often  an  impossibility  to  diagnosticate  between  them; 
syphilitic  stricture  is  unlike  all  other  lorms  of  stricture  save 
cancear.  Therefore,  if  it  proves  not  to  be  cancer,  it  must  of 
necessity  be  syphilitic.  I  am  sure  that  you  can  see  the  difference 
.between  such  a  statement  and  one  affirming  that  ninety-nine  out 
of  every  hundred  cases  are  syphilitc. 

What,  then,  are  we  to  do  with  syphilitc  ulceration  and  strict- 
ure of  the  rectum?  Permit  me  to  say  that  after  the  dise£se  as- 
sumes the  fibrous  nature  which  constitutes  a  stricture,  it  is 
utterly  incurable  by  either  local  medication  or  by  general  means. 
There  is  but  one  course  to  be  pursued  looking  to  a  radical  cure, 
and  that  is  the  entire  resection  of  the  affected  tissue.  The  question 
then  arises,  can  this  be  done?  Unfortunately,  the  case  in  which 
such  a  procedure  could  be  practiced  would  be  a  rare  one.  What 
course  is  left?  Nothing  save  proctotomy  and  colostomy,  either 
one  of  which  is  only  a  palliative  remedy.  This  is  indeed  a  mel- 
ancholy class  of  patients,  as  incurable  as  cancer,  with  the  disad- 
vantage over  the  latter,  that  life  is  for  a  much  longer  period  made 
a  thing  of  much  misery  and  suffering. 

3.   Cancerous.      Cancer  is    yet    the  "horror  of  horrors"  to  the 


262  MATTHEWS-RECTUM  SURGERY. 

medical  man.  In  its  presence  we  l)ow  submissively  in  ignorance 
and  acknowledge  our  inability  to  cope  with  the  monster.  Lo- 
cated in  certain  regions  of  the  rectum  it  assumes  new  features 
of  torture,  and  soon  evades  the  limits  of  surgical  interference. 
And  yet  surgery  has  done  much  in  the  last  decade  or  two  looking 
to  the  eradication  of  this  terrible  disease. 

In  times  past  it  would  have  been  thought  both  unwise  and 
unsurgical  to  have  attemped  the  removal  of  the  entire  rectum 
for  cancerous  or  other  disease.  To-day  it  is  often  practised. 
Let  us  for  a  moment  consider  whether  such  attempt  is  justifiable, 
and  if  so,  how  often?  No  one  denies  the  anatomical  and  surgical 
fact  that  the  rectum  can  be  removed  even  in  its  entirety,  but 
under  what  conditions  should  such  surgery  be  advocated?  In 
this  day  of  performing  great  surgical  feats,  there  is  such  a  thing 
as  overstepping  the  bounds  of  all  reason  in  order  to  show  great 
dexterity.  Because,  forsooth,  one  stomach  was  removed  and 
the  patient  lived,  is  no  reason  that  a  search  should  be  instituted 
for  stomachs  to  remove. 

It  is  a  principle  in  surgery  that  unless  all  tissues  involved  in 
the  cancerous  disease  can  be  removed,  an  operation  is  useless. 
It  is  a  well-recognized  fact  that  the  rectum  is  contiguous  to  a 
large  distribution  of  glands  and  lymphatics.  Cancer  situated 
above  and  not  involving  the  sphincter  muscle  is  often  an  insid 
ious  disease.  When  the  mass  has  so  far  extended  as  to  embrace 
the  whole  rectum,  it  is  safe  to  infer  that  the  infiltrative  process 
has  so  extended  that  it  has  embraced  structures  which  can  not 
be  removed  ;  hence  to  resect  simply  the  mass  in  sight  would  avail 
nothing.  Much  better  to  leave  snch  a  patient  to  the  tender 
mercy  of  an  opiate  than  to  further  wreck  life  by  a  fruitless 
major  surgical  operation. 

If,  on  the  contraiy,  the  growth  can  be  circumscribed,  and  the 
assurance  had  that  all  diseased  structures  can  be  removed,  then 
resection,  or  rather  extirpation,  should  be  advised. 

I  desire  to  say  in  this  connection  that  the  operation  is  much 
more  preferable  than  to  perform  a  colostomy  in  such  a  case. 
The  latter  can  only  be  palliative,  if  that,  while  the  former  antici- 
pates a  radical  cure.  There  have  been  a  number  of  methods 
proposed  for  accomplishing  the  removal  of  the  rectum,  but  the 
writer  prefers  to  avoid  such  operations  as   Kraske  recommends, 


MATTHEWS-RECTUM  SURGERY.  263 

if  a  lesser  one  will  accomplish  the  purpose.  I  have  practiced 
removinor  portions  of  the  rectum  by  the  simple  circular  incision 
ard  a  careful  dissection  of  the  gut  with  the  fingers.  In  a  few 
instances  I  have  removed  the  coccyx,  as  it  materially  increases 
the  field  in  which  to  work. 

Walker,  of  Detroit,  and  Tuttle,  of  New  York,  as  well  as 
Alexander,  have  in  my  opinion  improved  on  Kraske's  method. 
It  is  a  very  serious  question  to  decide  whether  this  operation 
should  be  recommended.  I  must  say  that  but  very  few  cases 
have  fallen  under  my  observation  where  I  thought  it  justifiable 
to  remove  so  much  of  the  rectum.  Infiltration  and  glandular 
enlargement  must  certainly  take  place  before  the  whole  rectum 
can  be  blocked  with  or  by  a  malignant  growth.  Upon  several 
occasions  I  have  had  to  abandon  the  operation  because  of  this 
fact,  and  regretted  that  I  had  ever  begun.  I  would  much  pre- 
fer to  remove  the  rectum  for  syphilitic  disease   than  for  cancer. 

Disease  of  the  Sigmoid  Flexure.  Before  closing,  you  will  per- 
mit me  to  call  your  attention  to  a  non-surgical  subject  that  has 
interested  me  for  a  long  time,  viz.,  disease  in  the  sigmoid  flex- 
ure. For  want  of  a  better  term  I  have  styled  the  trouble  sigmoid- 
itis. This  term  should  be  disassociated  from  the  secretion  neu- 
rosis of  the  colon,  such  as  pseudo-membraneous  colitis,  colitis 
tubulosa,  membranous  colitis,  etc.,  and  from  a  syphilitic  or 
tubercular  manifestation  in  the  colon.  O'Bierne,  of  Dublin, 
demonstrated  that  the  flexure  and  not  the  rectum  was  the  recep- 
tacle of  the  fecal  mass;  that  by  an  anti-peristaltic  movement 
the  feces  were  carried  back  and  deposited  in  the  flexure  if  not 
voided.  My  investigations  have  proven  this  to  be  true.  The 
water  is  rapidly  absorbed  and  the  dried  fecal  mass  is  left  in  the 
flexure  to  irritate.  As  a  result  we  have  a  congestion,  inflamma- 
tion, and  ulceration  of  the  flexure.  These  patients  suffer  from 
a  discharge  of  mucus  or  blood,  or  both,  and  ultimately  with  a 
muco-purulent  discharge.  This  condition  is  easily  mistaken  for 
a  flux  or  cancer.  They  can  be  quickly  relieved  by  an  early 
diagnosis  and  proper  local  treatment.  Internal  administration 
of  medicine  does  no  good,  but  a  great  deal  of  harm.  The  in- 
struments to  be  used  are  a  bulb  syringe  and  a  Wales  bougie. 
The  agents,  large  quantities  of  w-.rm  water,  or  boric  acid  water, 
fluid  hydrastis,  iodoform  oil,  etc.  They  will  often  clear  up  as 
if  b}'  magic. 

I  had  hoped  to  consider  the  subject  of  the  surgical  treatment 
of  ano-rectal  imperforation,  but  my  paper  is   already   too  long. 

Again  I  thank  you,  gentlemen,  for  your  many  courtesies. — 
Mattheivs  Quarterly  Journal. 


NORTH  CAROLINA  MEDICAL  JOURNAL, 

ROBERT  D.  JEWETT,  M.D.,  Editor 


DEPARTMENT  EDITORS 

(      H.  T.  Bahnson,  M.D.,  Salem,  N.C. 
SURGERY:     \      R.  L.  Gibbon, M.D.,  Charlotte,  N.  C. 

f      J.  Howell  W  ay,  M.D.,  Waynesville,  N.  C. 

NERVOUS  DISEASES:— J   LLISON  HODGES,  M.D.,  Rcilimond,  Va. 

PRACTICE  OF  MEDICINE.  ]    S-  ^f  ™^iit^^^.^g'.  ^^•^"  ^^  ^^  ^- 

nRQT^T?T-T?T<-«-      J      George  G.  Thomas,  M.D.,  Wilmington,  N.  C. 
OBblEiUiCb.      -j     p.    L.  Payne,  M.D.,  Norfolk,  Va. 

(      H.  S.  LOTT,  M.D.,  Winston,  N.  C. 
GYNECOLOGY:      \      J.  W.  Long,  M.D.,  Salisbury,  N.  C. 
(      H.  A.  ROYSTER,  M.D.,  Raleigh,  N.  C. 

PATHOLOGY:— Albert  Anderson,  M.D.,  Wilson,  N.  C. 
PEDIATRICS:— J.  W.  P.  Smithwick,  M.D.,  La  Grange,  N.  C. 
TRANSLATION  AND  FOREIGN  REVIEWS: 
Richard  H.  Whitehead,  M.  D.,  Chapel  Hill,  N.  C. 


All  communications,  either  of  a  literary  or  business  nature,  should  be 
addressed  to,  and  any  remittances  by  P.  O.  Order,  Draft  or  Registered  Let- 
ter, made  payable  to  Robert  D.  Jewett,   M.D.,  Winston,  N.  C. 

EMtonaL 


schleich's  method  of  general  an^thesia. 


While  the  death-rate  from  anaesthesia  is  by  no  means  large — 
one  in  two  thousand  from  chloroform,  and  one  in  ten  thousand 
from  ether,  according  to  various  observers — the  aggregate  is 
sufficiently  great  to  be  a  matter  of  or  very  serious  consideration 
by  medical  men.  Dr.  C.  L.  Schleich,  of  Berlin,  has  recom- 
mended a  method  which  seems  to  promise  better  results  for  the 
future.  He  reasoned  that  the  absorption  of  a  general  anaesthetic 
depends  upon  (i)  the  surrounding  temperature,  and  (2)  the 
boiling  point  or  maximum  of  evaporation  of  the  anaesthetic. 
In  the  inhalation  of  an  anaesthetic  having  a   low   boiling  point 


EDITORIAL.  265 

much  less  would  be  introduced  into  the  circulation  than  in  the 
case  of  one  with  a  high  point  of  maximum  evaporation.  If  the 
maximum  evaporation  approaches  the  temperature  of  the  body, 
the  lungs  alone  would  be  able  to  regulate  the  elimination,  ex- 
actly as  much  being  exhaled  as  inhaled.  With  an  anaesthetic 
with  a  maximum  evaporation  of  i40°F. — e.g.,  chloroform — a 
larger  quantity  is  absorbed  than  can  be  exhaled,  and  the  heart, 
kidneys  and  liver  must  be  called  into  action.  Sulphuric  ether 
with  a  maximum  evaporation  of  93°F.,  must  distend  the  pul- 
monary alveoli.  It  is  this  obstruction  to  respiration  that  causes 
a  certain  degree  of  cyanosis.  The  pressure  of  carbonic  acid 
accumulating  in  the  blood  partially  overcomes  this  tension,  and 
the  cyanosis  disappears  and  true  ether  narcosis  begins:  It  is 
evident  that  the  safest  anaesthetic  would  be  one  in  which  the 
amount  eliminated  by  expiration  would  nearly  equal  that  ab- 
sorbed during  inspiration. 

In  a  recent  paper  describing  this  method  of  anaesthesia  Dr. 
Willy  Meyer,  of  New  York,  enumerates  the  chief  features  of 
Schleich's  work  as  follows:  (i)  Our  familiar  anaesthetics,  ether 
and  chloroform,  were  mixed  with  a  benzin;  (2)  it  was  found 
that  by  so  mixing  various  ethereal  substances  the  resulting  fluid 
was  a  true  solution  in  a  chemical  sense,  and  not  a  mere  mixture 
of  different  ethereal  substances;  (3)  it  was  ascertained  that  by 
changing  the  proportion  of  the  constituents  we  -can  change  the 
boiling  point  at  will,  and  so,  in  a  given  case  adapt  the  max- 
imum evaporation  of  the  anaesthetic  to  the  temperature  of  the 
patient  at  the  time;  (4)  these  effects  were  found  to  hold 
good,  and  were  verified  in  coldblooded  as  well  as  in  warm- 
blooded animals;  (5)  the  result  is  the  same  whether  the  anaes- 
thetic was  inhaled,  given  by  rectum,  or  injected  subcutaneously  ; 
and  (6)  the  result  was  exactly  the  same  in  the  human  subject  as 
in  the  lower  animals.  He  recommended  three  different  solu- 
tions, made  up  by  volume  and  not  by  weight.  Solution  No.  i 
is  composed  of  chloroform,  1  j4  oz.  ;  petroleum  ether,  }4  oi.  ; 
sulphuric  ether,  6  oz.  Solution  No.  2  is  composed  of  chloro- 
form, i>^  oz.  ;  petroleum  ether,  }4  oz.  ;  and  sulphuric  ether,  5 
oz.  Solution  No.  3  is  composed  of  chloroform,  i  oz.  ;  petroleum 
ether,  ^  oz. ;  and  sulphuric  ether,  lyi  oz. 

Dr.    Meyer's  conclusions   were    based    upon   the   use  of    this 


266  REVIEWS    AND  BOOK   NOTICES. 

method  in  one  hundred  cases.  He  says  excitement  was  very 
rare  during  the  induction  of  anaesthesia  and  not  marked  at  any 
time.      There  is  rarely  accumulation  of  mucus,   never  cyanosis. 

During  the  stage  of  anaesthesia,  in  spite  of  the  fact  that  the 
solution  contains  sixty  to  eighty  per  cent,  of  sulphuric  ether, 
there  is  no  accumulation  of  mucus  and  cyanosis  is  rare.  Dur- 
ing this  stage  the  pulse  is  full  and  regular,  sometimes  fuller 
than  before.  The  respirations  are  not  impaired  so  long  as  the 
narcotizer  attends  to  his  work.  The  type  of  the  respiration  is 
the  direct  index  of  the  patient's  condition.  When  the  respira- 
tions become  deep  and  frequent,  it  indicates  the  approach  of 
the  danger  limit.  The  recovery  from  the  anaesthesia  is  more 
rapid  than  after  chloroform  or  ether.  Vomiting  occurs,  but 
less  frequently.  In  the  administration  he  believed  a  mask  which 
did  not  allow  free  evaporation  was  the  best.  The  amount  of 
anaesthetic  depended  on  the  kind  of  mask  and  the  solution  used. 
On  an  average  he  used  six  to  eight  ounces  for  an  operation 
lasting  forty-five  minutes  to  two  hours. 

As  in  nearly  all  new  things  in  medicine  the  first  cases  re- 
ported seem  to  show  unusually  good  results — it  may  be  on  ac- 
count of  the  especial  care  that  is  exercised — but  it  remains  to 
be  seen  whether  this  new  method  will  prove  more  satisfactory 
than  the  good  old  way  with  chloroform.  Dr.  Meyer  struck 
what  we  consider  the  key-note  in  the  successful  use  of  anaes- 
thetics generally  when  he  said  "the  respirations  are  not  im- 
paired so  long  as  the  narcotizer  attends  to  his  work,'"  but  just  so 
surely  as  the  important  duty  of  administering  the  anaesthetic  is 
entrusted  to  the  hands  of  incompetent  and  inattentive  persons, 
as  surely  may  we  expect  accidents  whether  the  anaesthetic  be 
chloroform,  ether  or  a  mixture. 


IReviewe  an^  Bool^  IRotices. 


New  Books. — Messrs.  Lea  Brothers  &  Co.,  announce  for  early 
publication  the  following  books  by  eminent  authorities.  Com- 
plete catalogues  of  the  publications  of  this  firm  may  be  had  by 


REVIEWS  AND  BOOK  NOTICES.  267 

addressing  either  their  Philadelphia  or  New  York  house. 

A  Manual  of  Otology.  By  Gorham  Bacon,  A.M.,  M.D.,  Pro- 
fessor of  Otology  in  University  Medical  College,  New  York. 
With  an  introductory  chapter  by  Clarence  J.  Black,  M.D.,  Pro- 
fessor of  Otology  in  the  Harvard  Medical  School,  Boston,  Mass. 
In  one  handsome  i2mo.  volume,  with  numerous  illustrations. 

The  Treatment  of  Surgical  Patients  before  and  after  Operation. 
By  Samuel  M.  Brickner,  M.D.,  Visiting  Surgeon  at  the  Mt. 
Sinai  Hospital,  New  York.  In  one  handsome  volume  of  about 
400  pages,  with  illustrations. 

A  Text-Book  of  Dental  Pathology,  Therapeutics,  and  Pharma- 
cology. Being  a  treatise  on  the  Principles  and  Practice  of  Dental 
Medicine.  By  Henry  H.  Burchard,  M.D.,  D.D.S.,  special  lec- 
turer on  Dental  Pathology  and  Therapeutics  at  the  Philadel- 
phia Dental  College,  Philadelphia.  In  one  handsome  octavo 
volume  of  about  550  pages,  with  400  illustrations. 

The  Principles  of  Treatment.  By  J.  Mitchell  Bruce,  M.D., 
F. R.  C.P.,  physician  and  lecturer  on  Materia  Medica  and  Ther- 
apeutics at  Charing-Cross  Hospital,  London.  In  one  octavo 
volume. 

Diseases  of  the  Hose,  Throat,  JVaso- Pharynx,  and  Trachea:  A 
manual  for  students  and  practitioners.  By  Cornelius  G.  Coak- 
ley,  M.D.,  Professor  of  Laryngology  in  University  Medical 
College,  New  York.  In  one  volume,  i2mo.,  of  about  400 
pages,  with  illustrations,  many  of  which  are  in  colors. 

Diseases  of  IVomen;  A  manual  of  non-surgical  gynecology, 
designed  especially  for  the  use  of  students  and  general  practi- 
tioners. By  Francis  H.  Davenport,  M.D.,  Instructor  in  Gyne- 
cology in  the  Medical  Department  of  Harvard  University, 
Boston.  Third  edition,  thoroughly  revised  and  enlarged,  with 
many  additional  illustrations. 

A  Treatise  on  Gynecology.  By  E.  C.  Dudley,  A.M.,  M.D., 
Professor  of  Gynecology  in  the  Chicago  Medical  College,  Chi- 
cago. In  one  octavo  volume  of  about  600  pages,  with  425  illus- 
trations, many  of  which  are  in  colors. 

Manual  of  Skin  Diseases.  With  special  reference  to  Diagnosis 
and  Treatment,  For  the  use  of  students  and  general  practi- 
tioners. By  W.  B.  Hardaway,  M.D.,  Professor  of  Skin  Dis- 
eases in  the  Missouri  Medical  College.      Second  edition,  entirely 


268  CURRENT   LITERATURE. 

rewritten  and  much  enlarged.      In  one  handsome  i2mo.  volume 
with  illustrations. 

The  Prificipies  and  Practice  of  Obstetrics.  By  American 
authois.  Edited  by  Charles  Jewett,  M.D.,  Professor  of  Obstet- 
rics in  the  Long  Island  College  Hospital,  Brooklyn,  N.  Y.  In 
one  handsome  octavo  volume,  with  many  illustrations  in  black 
and  in  colors. 


IRcvicw  of  Current  Xiteraturc. 


GENERAL  SURGERY. 

IN  CHARGE  OP 

H.  T.  Bahnson,  M.D.,  R.  L.  Gibbon,  M.D. 

J.  Howell  Way,  M.D. 


Injuries  of  the  Hand.— Dr.  R.  L.  Payne  of  Norfolk,  Va.,  formerly 
a  distinguished  North  Carolina  doctor,  contributes  an  interesting 
article  (Int.  Jour.  Sui-g. )  on  the  above  subject  from  which  we  quote: 

"The  treatment  of  injuries  of  the  hand  is  usually  relegated  to  the 
department  of  minor  surgery,  and  yet  no  class  of  injuries  demand 
greater  skill  and  judgment  for  their  successful  management,  and  in  no 
class  of  injuries  are  surgical  sins  more  common.  The  laudabte  desire 
to  obtain  a  condition  of  the  parts  in  which  rapid  healing  will  occur, 
together  with  the  thirst  for  operation  and  the  facility  with  which  opera- 
tions on  the  hand  may  be  done  under  local  anaesthesia,  are  responsi- 
ble for  many  of  the  mutilating  operations  done  in  injuries  of  the  hand; 
but  when  we  remember  how  essential  the  hand  is  to  the  maintenace  of 
the  life  and  happiness  of  the  individual,  we  may  well  raise  a  cry  for 
conservatism  and  carefully  consider  any  and  all  methods  looking  to 
the  preservation  of  this  important  member.  In  hemorrhage  in  injuries 
of  the  hand,  if  the  digital  vessels  be  divided,  it  is  usually  only  neces- 
sary to  apply  a  snugly  fitting  bandage  and  elevate  the  parts;  but  in 
injuries  of  the  palm  I  need  hardly  recall  the  fact  that,  because  of  the 
free  anastomosis  of  the  vessels  forming  the  palmer  arches,  it  is  neces- 
sary to  ligate  both  ends  of  the  divided  vessel,  and  this  should  always 
be  done  through  the  wound,  enlarging  it,  if  necessary,  and  making  the 
dissection  dry  by  means  of  the  Esmarch's  bandage.  In  some  cases, 
however,  for  one  of  many  reasons,  it  may  be  inexpedient  to   ligate  the 


CURRENT  LITERATURE.  269 

divided  arch,  and  then  the  following  method  may  be  used  with  the  best 
results:  The  hemorrhage  being  temporarily  restrained  by  the  elastic 
bandage,  or  otherwise,  the  wound  is  carefully  cleansed  and  dressed 
antiseptically.  Over  this  dressing  a  firm  ball  of  sterile  gauze  is  fixed 
in  the  palm  and  the  fingers  bandaged  firmly  over  it.  Long  strips  of 
adhesive  strap  are  now  laid  along  the  arm  from  just  above  the  elbow 
to  the  wrist,  and  the  bandage  carried  up  the  arm  over  these.  The  free 
ends  of  the  plaster  are  now  united  over  a  block  as  in  the  Buck's  exten- 
sion apparatus,  the  patient  is  placed  in  the  bed  lying  upon  his  back, 
and  the  arm  suspended  by  the  block  in  a  vertical  position,  so  that  all 
the  forces  of  gravity  are  brought  into  play  to  prevent  hemorrhage. 
In  from  twenty-four  to  thirty-six  hours  the  arm  may  be  lowered  into  a 
slightly  elevated  position,  and  at  the  end  of  forty-eight  hours  the 
dressing  may  with  safety  be  removed  and  changed.  This  plan  has 
sometimes  served  me  well  when  by  reason  of  poor  light  or  want  of  in- 
struments or  assistants  ligation  was  impracticable. 

A  finger  or  any  part  of  it  should  never  be  amputated  unless  its  con- 
dition is  such  that  its  nutrition  is  inevitably  destroyed.  There  is  only 
one  exception  to  this  rule,  and  that  is  where  the  joints,  and  especially 
the  metacarpo-phalangeal  joint,  a.re  so  much  injured  that  anchylosis  is 
inevitable:  then  the  stiff  finger  will  always  be  in  the  way  and  amputa- 
tion should  be  done  at  once.  If  a  portion  of  a  finger  be  cut  off 
smoothly  and  an  aseptic  condition  of  the  parts  can  be  obtained,  as  is 
usually  the  case,  then  io  is  not  necessary  to  cut  back  the  bone  as  is 
generally  done  in  order  that  its  end  may  be  covered  in,  for  if  the  parts 
be  kept  clean,  granulations  quickly  spring  up,  covering  in  its  end  and 
pi^eserving  a  greater  length  of  finger. 

The  next  point  in  the  management  of  this  class  of  injuries,  is  always 
take  care  of  injured  tendons.  Never  close  a  wound  of  the  hand  with- 
out having  first  carefully  examined  to  see  if  any  of  the  tendons  have 
been  divided,  and  if  so,  carefully  suture  with  catgut  ligature  the  di 
vided  ends,  and  if  the  wound  and  ligature  is  clean,  union  will  result, 
and  no  impairment  of  function  will  follow.  If  the  tentlon  is  so  lacer- 
ated or  contused  that  union  could  not  be  expected,  then,  with  sharp 
scissors,  cut  back  the  tendon  to  sound  tissue,  and  if  it  be  necessary,  in 
order  to  accomplish  this  end,  enlarge  the  wound,  and  then  having  cut 
off  the  ends  smoothly,  if  the  divided  tendon  cannot  be  sutured  without 
tension,  the  ends  may  be  united  with  long  stitches  of  catgut,  hoping 
that  along  this  framewo.ik  new  tendinous  structure  may  be  developed 
and  the  ends  thus  united,  or,  if  possible,  the  divided  ends  of  the  sheath 
may  be  stitched  together,  and  in  this  canal  a  connecting  tendinous 
band  will  gradually  develop.  All  of  these  methods  are  useful,  but  if 
the  ends  are  widely  separated  the  method  of  Czerny  is,  perhaps,  best 
of  all.  The  tendon  is  half  way  divided  at  a  proper  distance  from  its 
wounded  end,  and  the  free  end  of  the  split  portion  is  turned  downward 
and  sutured  to  the  end  of  the  distal  portion  of  the  divided  tendon.  If 
none  of  these  methods   are  feasible,    then  the  end    of  the  lower    por- 


270 


CURRENT   LITERATURE. 


tion  of  the  divided  tendon  may  be  sutured  to  any  other  tendon  run- 
ning the  same  course  and  having  sinailar  function. 

It  is,  however,  in  contused  and  lacerated  wounds  of  the  hand  that 
one  is  most  embarrassed  as  to  what  is  best  to  be  done.  Let  us  consider 
it  an  axiom  in  this  class  of  injuries  a  hand  that  is  almost  hopelessly 
crushed  will  often  assume  a  so  much  better  appearance  under  one  or 
two  dressings  that  much  that  was  apparently  lost  may  be  saved,  and 
the  great  necessity  of  saving  even  a  portion  of  a  finger  more  than 
counterbalances  the  danger  of  a  secondary  amputation.  It  is,  of 
course,  necessary  to  first  arrest  hemorrhage,  and  then  the  injuaed  parts 
must  be  cleansed  and  disinfected.  This  class  of  wounds  is  more  liable 
than  any  other  to  septic  infection.  The  vitality  of  the  tissues  is  ma- 
terially lowered  by  injury  to  the  circulation,  and  especially  the  capil- 
lary circulation,  and  phagocytosis  is  at  its  minimum  while  dirt,  grease 
—indeed,  any  and  all  s  orts  of  septic  matter  —are  ground  into  the  tissues. 
This  must  all  be  removed  with  the  greatest  care,  and  then  I  am  in  the 
habit  of  immersing  the  injured  parts  in  a  warm  solution  of  acetate  of 
aluminum.  This  is  one  of  the  least  irritant  and  most  deeply  penetrat- 
ing of  all  antiseptics  with  which  I  am  acquainted,  and  is  less  liable 
than  the  more  generally  used  corrosive  sublimate  to  coat  the  contused 
tissues  with  a  covering  of  coagulated  albumen  and  thus  seal  them 
against  the  penetration  of  antiseptics,  while  at  the  same  time  septic 
material  is  shut  in.  Following  the  immersion  the  injured  part  is 
placed  in  an  easy  position,  ample  provision  is  made  for  free  drainage, 
the  torn  and  contused  tissues  are  as  accurately  coaptated  as  possible, 
using  very  few,  if  any,  stitches,  and  the  whole  enveloped  in  wax  paper 
or  rubber  protective  to  prevent  evaporation.  No  attempt  is  usually 
made  at  this  first  dressing  to  cut  away  ragged  tissues,  because  when 
the  dressing  is  removed  at  the  end  of  twenty-four  hours,  much  that  ap- 
peared lifelese  will  be  found  assuming  a  healthy  appearance,  and  it  is 
usually  best  to  wait  till  nature's  line  of  demarcation  indicates  which 
tissues  should  be  removed.  From  day  to  day  the  dressings  are  re- 
moved and  the  parts  immersed  in  warm  solutions  of  acetate  of  alum- 
inum or  carbolic  acid  for  an  half  hour,  disorganized  and  sloughing 
tissues  are  from  time  to  time  separated  with  the  scissors,  and  the  warm 
wet  dressings  continued  till  a  clean,  granulating  wound  indicates  the 
substitution  of  the  usual  dry  dressings. 

One  word  as  to  punctured  wounds,  and  that  is  always  provide  for 
free  drainage,  and  do  this  without  delay.  In  this  class  of  wounds 
sepsis  is  almost  always  present,  and  pus  may  form  at  the  bottom  of 
such  wounds  and  burrow  deeply  at  work  upward  along  the  tendons, 
doing  irreparable  damage  almost  before  its  presence  is  suspected.  If 
we  neglect  to  provide  for  drainage  and  pus  makes  its  appearance,  then 
the  wound  must  be  freely  laid  open,  and  with  groovea  director  and 
knife  or  scissors  each  pocket  and  sinus  must  be  opened  up,  curetted 
and  scrubbed  with  1-500  sublimate  solution,  and  packed  with  iodoform 


CURRENT   LITERATURE.  27  I 

gauze.     In  this  way  only,  can  we  reasonably  hope  to  stay  the  process 
of  destruction. 

In  all  injuries  of  the  hand  early  and  persistent  passive  motion  may 
be  indicated  and  will  give  excellent  results.  J-  H.  W. 


PRACTICE  OF  MEDICINE. 

IN  CHARGE  OF 

S.   Westry  Battle,  M.D.,  U.  S.  N.,  Asheville,  N.  C. 


Malarial  Hematuria. — In  the  Monthly  Cyclopaedia  of  Practical  Medi- 
cine we  find  an  interesting  review  of  recent  opinions  regarding  the  use  of 
quinine  in  malarial  haematuria.  The  views  of  Italian  physicians  are  par- 
ticularly valuable  in  this  connection.  Their  great  experience,  owing  to  the 
numerous  malarial  districts  of  their  country,  added  to  their  innate  acumen, 
enables  them  to  advance  an  authoritative  opinion  on  the  subject. 

Baccelli  attributes  haemoglobinuria  of  malaria,  not  to  the  hsemoparasite, 
but  to  its  toxins.  Quinine  may  bring  it  on  even  in  moderate  doses.  He 
recognizes  four  classes:  (i)  Pernicious  malaria  with  haemoglobinuria  cured 
by  quinine;  (2)  mild  attacks  of  malaria  accompanied  by  haemoglobinuria  only 
when  quinine  is  given;  (3)  haemoglobinuria  coming  on  in  persons  who  have 
had  malaria  some  time  ago,  and  not  associated  with  quinine;  (4)  haemoglob- 
inuria, if  the  malarial  attack  require  it.  He  also  recommends  persulphate 
of  iron  and  inhalations  of  oxygen. 

More  to  the  point  are  the  views  of  Bastianelli,  who  regards  it  as  practically 
proved  that  haemoglobinuria  occurs  only  in  infections  with  the  aestivo-autum- 
nal  parasite.  An  interesting  observation  is  that  haemoglobinuria  following 
quinine  is  extremely  rare  in  Italy,  no  case  having  ever  been  reported  from 
the  Campagna.  The  frequency  with  which  these  cases  occur  increases  as 
one  passes  southward.  Haemoglobinuria  due  to  quinine  never  occurs,  ex- 
cepting in  patients  who  are  suffering  or  who  have  recently  suffered  from 
malarial  fever. 

The  haemoglobinuric  attack  is  produced  every  time  quinine  is  administered, 
whether  it  be  given  while  the  malarial  attack  is  in  progress  (Tomaselli)  or 
whether  it  be  given  when  the  malarial  infection  has  run  its  course  (Murri). 
Extremely  small  doses  are  capable  of  bringing  on  an  attack.  Quinine  haem- 
oglobinuria has  been  seen  in  patients  who  have  already  suffered  from  spon- 
taneous haemoglobinuria  (Murri).  The  preceding  malaria  creates  the  funda- 
mental disposition,  the  existing  malaria  the  accidental  disposition,  and  the 
quinine  the  provocative  agent. 

Quinine  haemoglobinuria  is  divided  into  two  forms: 

1.  That  occurring  during  the  paroxysm — paroxysmal  quinine  haemoglob- 
inuria is  divided  into  two  forms: 

2.  Postmalarial  quinine  haemoglobinuria. 


2-J2  CURRENT   LITERATURE. 

In  these  varieties  quinine,  through  a  very  considerable  length  of  time,  will 
produce  an  haemoglobinuria  whenever  administered.  There  are,  however, 
instances  where  the  haemoglobinuria  due  to  the  taking  of  quinine  occurs  only 
now  and  then  during  the  paroxysm.     These  cases  are  rare. 

As  regards  treatment,  Bastianelli  argues  that  the  course  to  be  pursued  de- 
pends upon  the  blood  examination.  If  hsemoglobinuria  occurs  during  a  ma- 
larial paroxysm  and  parasites  are  not  found,  either  as  a  result  of  previous  ad- 
ministration of  quinine  or  on  account  of  the  spontaneous  disappearance  of 
the  organisms,  we  may  remember  that  the  administration  of  quinine  will 
have  no  effect  upon  this  attack  and  that,  for  the  time  being,  certainly  another 
attack  is  not  to  be  expected.  In  these  cases  Bastianelli  considers  quinine  as 
contra-indicated  owing  to  the  possibility  that  the  paroxysm  may  have  been 
due  to  its  previous  administration. 

If  in  an  attack  occuring  in  the  middle  of  an  ordinary  malarial  paroxysm 
there  arises  doubt  as  to  its  origin  from  quinine,  it  is  well  to  abstain  from  fur- 
ther administration  of  the  remedy,  for  the  quinine  already  given  is  usually 
sufficient  to  hinder  the  development  of  a  new  febrile  paroxysm.  But,  if,  in 
an  haemoglobinuric  attack  which  has  come  on  after  the  giving  of  quinine,  the 
parasites  are  still  found  in  the  blood,  one  is  justified,  despite  the  danger,  in 
insisting  upon  the  specific  treatment;  if  there  be  doubt  as  to  the  origin  from 
quinine,  we  may  be  sure  what  the  result  will  be  if  we  allow  the  parasites  to 
go  on  developing,  and  it  is,  therefore,  safer  to  interfere. 

Dr.  Meek,  who,  as  already  stated,  objects,  with  other  American  authori- 
ties, to  the  use  of  quinine,  recommends  the  following  treatment:  i.  Sodium 
hyposulphite  in  drachm  doses  every  two  hours  until  the  patient  is  thoroughly 
purged;  continued  in  smaller  doses  until  the  system  is  saturated  with  it. 
This  is  a  stimulant  to  the  hepatic  secretion,  causing,  in  large  doses,  an 
abundant  biliary  secretion ;  and  is  also  a  valuable  intestinal  antiseptic.  He 
believes  that  free  sulphurous  acid  is  disengaged  in  the  blood,  and  that  this 
agent  is  an  antizymotic  to  such  an  extent  that  it  destroys  the  micro-organ- 
isms that  are  the  real  cause  of  the  disease,  and  thus  arrests  the  process  of 
corpuscular  disintegration.  2.  Morphine  and  atropine  hypodermically,  suf- 
ficient to  quiet  the  stomach;  and  blisters  over  the  epigastrium,  if  necessary. 
3.  An  abundance  of  water  to  wash  out  the  coagula  that  must  necessarily 
accumulate  in  the  urinary  tubules  after  a  hjemorrhage.  Hot  water  or  hot 
lemonade  is  frequently  better  borne  by  the  stomach  than  cold.  Cupping  over 
the  loins  is  also  to  be  recommended.  4.  A  mild  diet;  fresh  butter-milk  is 
usually  well  borne,  and  also  acts  as  a  mild  diuretic.  5.  The  patient  should 
remain  in  a  strictly  recumbent  position. 


Now  is  a  good  time  to  subscribe  for  the  Journal. 


(Iberapeutic  Mnte. 


Antineuralgic   Liximknt. 

]^ — Ichthyol I  part. 

Mercury  ointment    .     .      .     .  i     " 

Chloroform 6     " 

Spts.  Camphor 6     " 

M.  Externally.  Shake  well.  Rub  upon  affected  parts. — 
Med.    Weekly. 

Neurasthenia. — The  following  prescription  has  been  useful 
in  the  treatment  of  some  of  the  cases  of  neurasthenia  seen  in 
Dr.  Spiller's  clinic: 

Tincture  of  nux  vomica     .      .      .      .      lo  minims. 

Sodium  bromid lo  grains. 

Compound  tincture  of  cardamom  suf- 
ficient to  make i  fluidra-n. 

Mix. 
Directions. — One  dose  to  be  given  three  times  daily  in  a  wine- 
glassful  of  water  after  meals.— /'/^V.  Polyclinic. 

iNCOiMPATIBILITY     OF     CaLOMEL     WITH     CHLORIDES,    AciDS,    AND 

Albuminoids. — Articles  and  notes  in  journals  and  text  and  ref- 
erence books  on  Incompatibility  have  repeatedly  warned  the 
pharmacist  that  chlorides  and  certain  acids  "oxidize,"  or  better, 
convert,  calomel  (mercurous  chloride)  into  corrosive  sublimate 
(mercuric  chloride).  Now,  however,  Jovanne  {Fharm.  Rund- 
schau) declares,  as  tlie  result  of  very  thorough  test-tube  experi- 
ments, that  calomel  is  not  changed  into  corrosive  sublimate 
either  by  chlorides,  inorganic  or  organic  acids.  This  is  con- 
trary to  the  belief  of  the  past,  but  to  substantiate  his  discov- 
eries Jovanne  administered  to  sixty  children  calomel  in  connec- 
tion with  lemonade  containing  hydrochloric,  citric  and  tartaric 
acids,  with  broth  containing  salt,  and  with  orange  juice.  No 
ill  effects  resulted.  Experiments  on  dogs  were  attended  with 
similar  results. — Bull,  of  Phar. 


When  writing  to  advertisers  please  mention  the  Journal. 


PUBLIC  SERVICE. 

From  March  24,  1898,  to  April  6,  1898. 

The  order  assigning  ist  Liet.  Bailey  K.  Ashford,  assistant 
surgeon,  to  station  at  Fort  Sam  Houston,  Texas,  is  revoked 
and  he  is  ordered  to  Fort  St.  Philip,  Louisiana,  for  duty  at  that 
post. 

Capt.  Joseph  T.  Clarke,  assistant  surgeon,  is  relieved  from 
duty  at  Columbus  Barracks,  Ohio,  and  ordered  to  Madison 
Barracks,  New  York,  for  duty,  relieving  Capt.  Paul  Shillock, 
assistant  surgeon.  Capt.  Shillock  upon  being  so  relieved,  will 
proceed  to  Key  West,  Florida,  and  report  to  the  commanding 
officer,  25th  Infantry,  for  duty  with  that  regiment. 

ist  Lieut.  George  Rauchfuss,  assistant  surgeon,  resigned 
April  2,  1898. 

Capt.  Edward  Everts,  assistant  surgeon,  upon  the  abandon- 
ment of  Whipple  Barracks,  Arizona,  Ty.,  is  ordered  to  Fort 
Apache,  Ariz,  ist  Lieut.  Alexander  S.  Porter,  assistant  sur- 
geon, is  relieved  from  duty  at  Whipple  Barracks,  Arizona,  and 
upon  expiration  of  his  present  leave  of  absence  is  ordered  to 
San  Diego  Barracks,  California,  tor  duty. 

The  order  assigning  ist  Lieut.  George  Rauchfuss,  assistant 
surgeon,  to  Fort  Apache,  Arizona  Ty. ,  is  revoked. 
Leave  of  absence  for  four  months,  on  surgeon's  certificate  of 
disability,  to  date  from  his  arrival  at  the  Army  and  Navy  Gen- 
eral Hospital,  Hot  Springs,  Arkansas,  is  granted  Maj.  Henry 
McElderry,  surgeon. 

The  leave  of  absence  on  surgeons  certificate  of  disability 
granted  Maj.  Charles  K.  Winne,  surgeon,  is  further  extended 
six  months  on  surgeon's  certificate  disability. 

Capt.  Robert  J.  Gibson,  assistant  surgeon,  is  relieved  from 
duty  at  Fort  Thomas,  Kentucky,  and  ordered  to  Fort  Meade, 
South  Dakota,  for  duty. 

Maj.  Louis  W.  Crampton,  surgeon,  will  be  relieved  from  duty 
at  Fort  Mead,  S.  D.,  upon  the  arrival  there  of  Capt.  Gibson, 
and  is  ordered  to  Fort  McHenry,  Md.  to  relieve  Maj.  Charles 
K.  Winne,  surgeon. 

Maj.  Henry  McElderry,  surgeon,  now  at  Fort  Leavenworth, 
Kansas,  will  proceed  to  Hot  Springs,  x\rkansas,  and  report  to 
the  commanding  officer  of  the  Army  and  Navy  General  Hospital 
for  treatment  therein. 


'Uotce  anb  llteme. 


Dr.  C.  Daligny  has  removed  from   Thompsonville  to  El  Do- 
rado, N.  C. 


NOTES  AND  ITEMS.  275 

"OLE  DOCTEUR  FISET,"  WHO  HAS  "GOT  NINETY 
YEARS  OR  SO." 

But  Docteur  Fiset,  not  moche  fonne  he  get, 

Drivin'  all  over  de  whole  contree; 
If  de  road  she's  bad,  if  de  road  she's  good. 
When  ev'ryt'ing's  drown  on  de  Spring-tam  flood. 

An'  working  for  not'ing  half  time  mebbe! 

Let  her  rain  or  snow,  all  he  want  to  know 

Is  jus'  if  anywan's  feelin'  sick, 
For  Docteur  Fiset  's  de  ole-fashion  kin', 
Doin'  good  was  de  only  t'ing  on  hees  min', 

So  he  got  no  use  for  de  politique. 

— British  Medical  Journal. 

Epileptic  Colony. — The  Legislature  of  New  Jersey  has 
passed  a  bill  appropriating  $15,000  for  an  epileptic  colony. 

Puzzling  Cases. — An  apparently  healthy  child,  a  girl  of  ten, 
had  acute  curvature  of  the  spine.  Physicians  were  consulted 
by  the  solicitous  parents,  and  mechanical  devices  were  spoken 
of  among  several  suggested  methods  of  treatment.  The  physi- 
cian upon  one  occasion  called  at  the  house  to  examine  the  child, 
and  when  she  came  into  the  room  he  noticed  that  she  was  carry- 
ing upon  one  shoulder  a  large  pet  cat  of  which  she  was  very 
fond.  Upon  inquiry  it  was  learned  that  the  girl  was  in  the 
habit  of  carrying  this  cat  several  hours  a  day,  and  always  upon 
the  same  shoulder,  which  was  also  raised  to  make  a  better  rest- 
ing-place for  the  cat.  The  physician  ordered  the  cat  to  be  car- 
ried upon  the  other  shoulder  for  a  week,  then  to  be  carried  no 
more,  whatever.  The  spinal  column  soon  became  perfectly 
straight  and  normal.—/'////.  Med.  Jour. 

Women  Doctors. — This  country  is  undoubtedly  the  happy 
hunting-ground  of  the  woman  doctor.  The  increase  in  her 
numbers  has  within  the  last  twenty  years  been  phenomenal.  It 
is  estimated  that  there  are  now  about  4500  woman  practitioners 
in  America  as  against  527  in  1870.  The  majority  ot  these  are, 
of  course,  general  practitioners,  but  there  are  as  well  homeo- 
pathists,  hospital  physicians  and  surgeons,  professors  in  schools, 
specialists  for  diseases  of  women,    alienists,    orthopedists,  ocu- 


2j6  NOTES    AND  ITEMS 

lists,  aurists  and  electro-therapeutists.  Doubtless  like  their 
brothers  they  suffer  from  the  stress  of  keen  competition,  but  it 
is  stated  that  most  of  them  succeed  in  rmaking  good  headway, 
while  one  or  two  of  the  leading  lights  are  credited  with  amass- 
ing the  eminently  satisfactory  income  of  $25,000. — Med.  Record. 

Is  A  Violent  Death  Painful. — Severe  injuries  to  the  body 
are  seldom  very  painful  at  first.  The  severity  of  the  nervous 
shock  seems  to  paralyze  the  nerve  centre  where  consciousness 
of  pain  is  situated,  and  in  fatal  cases  there  is  often  no  sense  of 
pain,  even  when  death  is  delayed  a  day  or  two.  In  such  cases 
it  may  be  supposed  that  the  shock  not  only  paralyzes  but  even 
destroys  the  nerve  centre.  It  may  be  compared  to  a  lightning 
flash  along  the  telegraph  wires,  which,  although  of  the  same 
nature  as  the  electric  telegraph  current,  yet  is  so  intense  as  to 
destroy  the  receiving  instruments,  so  that  no  subsequent  mes- 
sages can  be  received.  In  some  fatal  injuries  the  nerve  that 
would  carry  the  pain  to  the  brain  is  destroyed,  and  such  acci- 
dents are  almost  painless.  Our  sense  of  pain  is  greatest  in  the 
skin,  and  deep  wounds  are  therefore  not  more  painful  than 
shallow  ones.  In  surgical  operations  the  skin  incision  is  often 
the  most  painful  part,  and  those  who  have  been  run  through 
the  body  say  they  were  conscious  only  of  something  cold  pass- 
ing through  them,  with  just  a  prick  at  the  points  of  entry  and 
exit  of  the  weapon.  On  the  other  hand,  some  fatal  injuries  are 
very  painful,  especially  those  that  interfere  with  breathing,  such 
as  injuries  to  the  chest  and  throat. — New  York  Advertiser. 

English  in  Prescription-Writing. — We  think  it  time  that 
Latin  should  not  be  used  any  longer  in  writing  prescriptions. 
There  is  not  one  in  a  hundred  physicians  who  can  write  Latin 
correctly,  and  a  prescription  that  is  one-half  or  one- fourth  in 
Latin  and  the  rest  in  English  is  bastardly  ridiculous.  We  all 
hide  our  philologic  ignorance  under  contractions  that  lead  to 
ambiguity  and  even  danger,  and  when  we  can  no  longer  hold 
out  with  our  wretched  sham  we  are  compelled  to  plunge  into 
English  for  the  directions.  All  arguments  for  this  medieval 
nonsense  do  not  amount  to  a  pinch  of  snuff.  As  for  hiding  the 
knowledge  of  the  drug  from  the  patient  and    the    advantage  to 


NOTES   AND  ITEMS.  277 

patients  traveling  abroad,  the  facts  need  only  to  be  looked 
squarley  in  the  face,  and  the  argument  for  Latin  becomes  a 
bad  boomerang.  The  practice  is  a  pompous  bit  of  humbug 
wich  shoud  be  left  to  medievalists  and  not  scientists.  So  soon 
as  we  get  our  therapeutics  out  into  the  daylight  of  common 
sense  and  genuine  science  we  shall  surely  dispense  with  the  sorry 
jumble  of  bad  Latin  and  poor  English  illustrated  by  nine-tenths 
of  the  actual  prescriptions  on  file  to-day  at  the  drug-stores. — 
Philadelphia  Med.  Jour. 

Passage  of  Substances  Through  the  Placenta. — A.  Sicard 
and  R.  Mercill  reported  before  the  Biological  Society  of  Paris 
on  January  15,  1898,  the  results  of  their  explacenta.  Injections 
were  made  into  primiparae  and  multiparae  from  three  minutes  to 
twenty-two  hours  before  delivery.  The  shortest  time  taken  for 
the  passage  of  the  blue  into  the  urine  of  the  child  was  one  hour 
and  twenty  minutes.  The  women  were  all  healthy,  having  no 
history  of  tuberculosis  or  of  syphilis.  In  no  case  did  the  pla- 
centa show  any  macroscopic  change. — La  Ecv.  Med. 

Longevity  of  Germs  in  Dust. — In  a  recent  number  of  the 
Annals  de  Micrographie,  Dr.  Miguel  gives  the  results  of  some  in- 
teresting observations  made  by  him  in  respect  to  the  vitality  of 
disease  germs.  In  May,  1881,  he  took  some  earth  from  the 
Montsouris  Park,  at  a  depth  of  ten  inches  below  the  turf.  This 
he  dried  for  two  days  at  a  temperature  of  30°  C,  and  then  he 
placed  the  dust  in  hermetically  sealed  tubes  which  he  put  aside 
in  a  dark  corner  of  the  laboratory.  When  taken,  the  soil  con- 
tained an  average  of  six  and  one-half  million  bacteria  per  gram. 
After  desiccation  the  number  had  fallen  to  rather  less  than  four 
million.  Sixteen  years  later — that  is  to  say,  last  year— he  still 
found  thiee  and  one  half  million  per  gram,  and  he  was  enabled 
to  isolate  the  specific  microbe  of  tetanus.  The  inoculation  of 
this  soil  in  guinea-pigs  determined  death  from  tetanus  after  an 
incubation  period  of  two  days,  showing  the  remarkable  vitality 
of  pathogenic  microbes  under  favorable  conditions. — Medical 
Press. 

The  Board  of  Medical  Examiners  will  meet  in  Charlotte,  N. 
C,  April  28  to  May  3,  1898.      The   time   for   meeting   was  first 


278  NOTES    AND  ITEMS. 

made  May  2-6,  but  the  Secretary  of  the  Board,  Dr.  H.  B. 
Weaver,  of  Asheville,  has  just  sent  out  notices  of  the  change. 
We  are  pleased  to  note  this  change  in  as  much  as  it  will  give 
opportunity  for  the  applicants  to  finish  their  work,  and  attend 
the  meeting  of  the  Society,  which  will  be  held  May  3rd,  4th, 
and  5th.  They  will  also  probably  have  the  verdict  passed  upon 
their  papers  in  time  for  the  successful  applicants  to  present  their 
names  for  membership  in  the  Society.  We  hope  that  all  who 
are  successful  will  take  advantage  of  the  opportunity  and  asso- 
ciate themselves  with  this  body  of  their  professional  brethren 
and  lend  their  influence  in  promoting  the  welfare  of  the  pro- 
fession in  the  State. 

Hospitals  Closed. — Misfortune  is  befalling  certain  hospitals 
as  a  result  of  the  consolidation  of  cities  to  form  Greater  New 
York.  The  Astoria  (Long  Island)  Hospital,  which  was  estab- 
lished by  the  women  of  Astoria  section  of  Long  Island  City, 
closed  its  doors  on  the  first  of  the  present  month.  Under  the 
new  charter,  the  city  authorities  are  notpermited  to  send  public 
patients  to  the  hospital,  and  the  institution  could  not  be  suc- 
cessfully conducted  without  the  income  thus  secured.  As  a  last 
resort,  the  managers  endeavored  to  form  a  union  with  some  other 
hospital  entitled  to  receive  patients  at  the  city's  expense,  but 
their  efforts  were  unavailing.  St.  John's  Hospital,  also  in  Long 
Island  City,  and  the  Flushing  Hospital  are  in  a  similar  financial 
predicament.  Last  year  an  addition  to  the  former  hospital, 
which  is  managed  by  the  Sisters  of  St.  Joseph,  was  commenced. 
It  was  designed  to  cost  $100,000,  but  when  nearing  completion, 
work  had  to  be  suspended  because  of  lack  of  funds.  Resort  has 
been  had  to  the  authorities,  but  it  is  hardly  likely  that  any 
material  aid  will  be  secured. — Phil.  Med.  Jour. 

The  Modern  Deterioration  of  Memory. — A  teacher  of  50 
years  of  experience  in  our  public  schools  says  the  modern  child 
is  greatly  inferior  to  the  child  of  50  years  ago  in  the  power  of 
memory.  The  fact  seems  beyond  question,  and  should  give 
cause  for  pondering  to  our  pedagogic  scientists.  We  have 
seen  school-books  in  which  the  simplest  tables  of  weights  and 
measures,  the  multiplication-table,  etc.,  were  placed  at  the  back 


NECROLOGY.  270 

(.f  the  book/^r  reference.  It  is  said  that  the  most  and  best  edu- 
cated man  nowadays  is  not  he  who  knows  most,  but  only  he 
who  best  known  where  knowledge  is  to  be  found.  In  the  im- 
mense complexity  of  modem  life  and  knowledge,  this  one-sided 
dictum  has  a  certain  amount  of  truth,  but  the  question  remains: 
Should  there  not  be  some  basis  of  the  memorized  known?  We 
have  seen  modern  school-children  studying  all  sorts  of  adult 
higher  subjects  a  dozen  years  beyond  them,  and  yet  who  did 
not  know  their  alphabet, — at  least  couldn't  pronounce  the  letters 
when  they  saw  them.  Are  we  not,  indeed,  confusing  mental 
evolution  and  killing  memory  by  modern  pedagogic  methods? 
Does  not  the  superficial  smattering  of  a  hundred  things  weaken 
both  menmonic  power  and  real  logical  ability?  Recently,  in 
answer  to  a  question  why  the  days  were  longer  in  summer  than 
in  winter,  one  of  these  products  of  over-pressure  and  mechanical 
education  answered  that  "it  is  the  natural  result  of  heat  to 
elongate  things. "  That  is  the  kind  of  logic  that  is  quite  popular 
at  present.  How  much  is  our  public-school  system  responsible 
for  it? — Phil.  Med.  Jour. 


NECROLOGY. 


Dr.  A.  Russell  Strachan,  aged  70  years,  at  New  York,  March 
I,  1898.  He  received  fatal  injuries  v;hile  bravely  risking  his 
own  life  to  save  a  woman  and  child  from  being  run  over  by  a 
cable  car.      The  woman  and  child   were  gotten  out  of  the  way. 

Dr.  W.  H.  Johnston,  aged  59  years,  at  Birmingham,  Ala., 
April  3,  1898.  He  was  a  native  of  Lincoln  Co.,  N.  C,  edu- 
cated at  Davidson  college  and  che  University  of  North  Caro- 
lina. He  served  in  the  23rd  N.  C.  Infantry  during  the  war 
between  the  States.  He  graduated  in  medicine  from  the  Uni- 
versity of  the  City  of  New  York. 


Now  is  a  good  time  to  subscribe  for  the  Journal. 


IReabing  IRotices, 


A  Food  for  Diarrhoea  in  Infants. — The  difficulty  of  feed- 
ing children  suffering  from  diarrhoeal  troubles  has  long  been 
recognized  by  pediatricians.  In  many  of  these  cases,  milk  must 
be  entirely  discarded  and  replaced  by  other  foods.  The  idea 
not  long  ago  occurred  to  a  German  chemist  that  by  converting 
albuminous  constituents  of  milk  into  albumoses,  they  would  be 
not  only  more  readily  absorbed  and  assimilated,  but  would  also 
be  less  irritating  to  the  mucous  membrane  of  the  alimentary 
tract.  It  was  further  found  that  by  addition  of  a  small  precent- 
age  of  an  astringent  (tannic)  in  firm  organic  combination  with 
the  albumoses  base,  an  unirritating  and  nutritious  food  product 
is  secured,  of  especial  value  in  diarrhoeal  affections.  This  pro- 
duct has  been  introduced  under  the  name  of  lacto-somatose,and 
has  been  thoroughly  tested  in  the  medical  clinic  of  Bonn  and 
other  institutions  in  Germany. 

The  results  thus  far  obtanied  are  so  satisfactory  as  to  encour- 
age extensive  use  of  this  astringent  nutritive  preparation  in  all 
diarrhoeal  troubles  wliere  other  foods  are  not  tolerated. 

Pain  in  Otitis. — Dr.  George  H.  Powers,  Professor  of  Opthal- 
mology  and  Otology  in  the  University  of  California,  San  Fran- 
cisco, in  an  article  in  The  Medical  News^  writes  as  follows,  in 
reference  to  the  treatment  of  pain  in  otitis:  "At  my  first  visit  I 
found  a  copious  discharge  of  bloody  serum  from  the  ear  with 
hardly  a  trace  of  pus.  He  suffered  from  severe  cephalalgia, 
but  there  was  no  special  tenderness  in  or  about  the  ear,  and  no 
swelling.  Thorough  cleansing  of  the  meatus  with  dry  cotton 
relieved  the  pain  in  the  head  remarkably,  and  with  a  dose  of 
antikamnia,  lo  grains,  he  slept  some  hours." 

Sanmetto  the  Standard  Preparation  for  Genito-Urinary 
Diseases. — For  some  years  I  have  been  a  very  warm  admirer  of 
Sanmetto,  and  have  found  its  action  marked  and  well  defined  in 
the  cases  wherein  I  have  used  it.  In  cases  of  prostatitis,  with 
loss  of  virile  power  in  elderly  men  I  find  its  action  superb.  In 
chronic  specific  urethritis,  cystitis  and  all  irritable  conditions  of 
the  urinary  tract  I  find  Sanmetto  very  efficacious.  I  do  not 
hesitate  to  recommend  it  as  a  standard  preparation  in  cases  where 
the  action  of  pure  santal  and  saw-palmetto  is  indicated. 

Durand,  Mich.  Jos.   Marshall,    M.D. 


Functional  Wrongs  of  Women.— For 
he  functional  wrongs  of  women  Ale- 
Ris  Cordial  (Rio)  possesses  remarka- 
le  curative  influence.    It  exerts  its 
pecial  tonic  action  action  on  the  whole 
terine  system,  and  it  is  therefore  indi- 
cted in  all  abnormal  conditions  of  the 
imale  system,  without  regard  as  to 
^hether  it  is   Dysmenorrhea,  Menor- 
I'Bgia,    Leucorrhea,    Amenorrhea,    or 
ly  other  functional  wrong  peculiar  to 
le  female.     Women  suffering  from  an 
ching  Back,   Bearing-Down   Abdom- 
al  Pains,  or  Soreness  in  the  Lumbar 
egion,    should    be    given  ALETRIS 
DRDIAL  in  teaspoonful  doses— four 
'  five  times  a  day. 

A    sample    bottle    will    be   sent   free  to  any  physician   who  desires  to 
test  it,  if  he  will  pay  the  express  charges. 

RIO  CHEMICAL  CO.,  St.  Louis,  Mo.,  U.  S.  A. 


NORTH  CAROLINA 

MEDICAL  JOURNAL 


A  SEMI-MONTHLY  JOURNAL  OF  MEDICINE  AND 
SURGERY. 

Vol.  XLI.  Winston,   May  5,    1898,  No.   9. 


©nginal  Communicatione. 


PRESIDENT'S  ADDRESS.* 
By  Francis  Duffy,   M.D.,   Newbern,   N.  C. 


Gentlemen  of  the  Medical  Society  of  the  State  of  North  Carolina: 

In  accordance  with  the  rules  of  this  Society,  it  becomes  my 
duty  to  present  to  you  an  address  on  assuming  the  functions  of 
the  offie  to  which  you  have  done  me  the  honor  to  call  me. 

Some  of  the  presiding  officers  in  our  past  history  have  dis- 
cussed medical  topics  by  inviting  the  attention  of  the  society  to 
some  chosen  subject,  others  have  looked  over  the  field  which  we 
occupy  and  have  advised,  according  to  their  judgment,  such 
action  as  was  likely  to  promote  the  objects  which  we,  co-laborers, 
are  seeking  to  attain,  while  other  addresses  have  been  inspir- 
ing and  elevating  by  sentiments  expressed,  not  merely  rhe- 
torical and  pleasing  the  ear,  but  utilitarian  in  the  highest  sense, 
like  a  poem,  which  by  stirring  and  emotions  builds  resolve,  and 
has  its  fruition  in  the  best  deeds  of  men. 

I  desire  to  submit  to  your  consideration  certain  matters  which, 
during  my  connection  with  the  Society,  have  occurred  to  my 
mind  from  time  to  time.  B'irst,  as  to  the  necessity  of  increasing 
the  membership  and  usefulness  of  our  Society.  It  is  obvious 
that  all  the  legislation  regulating  the  practice  of  medicine  and 
maintaining  a  higher  standard  of  medical  education  in  the  State 

*Read  at  45th  Annual  Meeting  of  the  North  Carolina  Medical  Society,  Char- 
lotte, May  3,  1898. 


282  PRESIDENT'S   ADDRESS. 

has  oris^inated  in  the  presistent  organized  efforts  of  the  Nortfif 
Carolina  Medical  Society.  The  same  may  be  said  as  to  the  en- 
actment of  laws  establishing  the  Board  of  Health,  or  in  any  re- 
spect pertaining  to  public  sanitation.  As  the  importance  of  these 
matters  can  hardly  be  over-estimated,  it  isevident  that  anything 
tending  to  build  up  the  Society  and  increase  its  power  must  be 
of  corresponding  importance.  In  this  connection  I  call  atten- 
tion to  the  fact  that  since  written  examinations  have  been  adopted 
by  our  Medical  Examining  Board,  it  has  been  impracticable  for 
licentiates  of  the  Board  to  join  the  Medical  Society  during  the 
meeting  at  which  they  were  licensed.  Reference  to  Society 
Annals  will  show  that  a  much  larger  number  have  been  licensed 
than  have  become  members  of  the  Society  at  the  same  session. 
These  young  men  form  the  best  element  from  which  to  recruit 
the  ranks  of  the  Society.  When  they  miss  the  first  opportunity, 
they  do  not  as  a  rule  have  the  same  interest  in  public  medical 
affairs  that  they  would  have  as  members  of  the  Society. 
They  do  not  often  go  long  distances  to  join,  but  wait 
one  of  the  migratory  incursions  which  does  not  usually  occur 
oftener  than  once  in  a  decade.  If  our  Medical  Examinidg  Boards 
would  shold  their  meetings  long  enough  before  the  Society  met 
to  finish  their  examinations  and  report  thereon  before  the  ad- 
journment of  the  Society,  these  disadvantages  would  be  obvi- 
ated, and  at  the  same  time  the  law  complied  with,  which  r  quires 
that  the  Board  should  meet  at  the  same  time  and  place  as  the 
Medical  Society. 

I  believe  it  would  be  well  to  remit  the  usual  initiation  fee  to 
those  who  join  during  the  year  in  which  they  receive  their  licenses 
This,  instead  of  being  a  loss  to  the  Society,  would  likely  be  a 
gain,  as  the  annual  dues  in  2^  years  will  amount  to  $5.00,  while 
the  average  length  of  time  which  elapses  before  the  joining  of 
those,  who  join  at  all,  is  much  longer  than  that  period,  wliile 
many  never  become  members  of  the  Society;  besides  many  meri- 
torious young  men  have  spent  all  their  money  in  obtaining  medi- 
cal education  and  license,  and  have  not  even  $5.00,  to  spare  at 
the  time  they  have  to  equip  themselves  for  practicing  their  pro- 
fession. There  are  other  reasons  than  those  I  have  touched  upon, 
why  the  way  should  be  made  easy  for  young  men  to  join  the 
Society.      The  first  year  of  professional  life  is  the  formative  stage 


PRESIDENT'S    ADDRESS.  28 ■? 

of  professional  character.  The  moral  sense  and  those  delicate  in- 
stincts, which  point  to  rectitude  as  their  polar  star,  are  not  strong 
alike  in  all,  nor  have  the  home  influences  and  other  sources  of 
training  which  build  upon  the  foundations  of  character  been  the 
same.  Young  men  of  various  bias,  without  any  knowledge  of 
the  Code  of  Medical  Ethics,  enter  a  profession  which  from  the 
time  of  Hypocrates  has  had  its  Ethical  Code,  and  which  as  it  is 
to-day  is  the  outgrowth  of  the  wisdom  and  experience  of  gener- 
ations of  practitioners  who  stand  upon  the  delicate  ground  where 
meet  self  interest  and  self  abnegation.  These  first  years  of  pro- 
fessional life  ar€,  with  many,  associated  with  necessities  which 
would  naturally  foster  carelessness.  Is  it  any  wonder  that  there 
are  so  many  deviations  from  the  paths  of  moral  and  Ethical 
rectitude? 

The  influence  of  a  Medical  Association  is  very  beneficial  in 
forming  and  promulgating  rules  to  harmonize  and  make  pleasant 
the  business  relations  of  medical  men;  in  stimulating  the  efforts 
of  co-workers,  by  which  they  become  co-educators  and  in  inspir- 
ing higher  ideals  from  which  spring  higher  realizacions. 

I  trust  it  is  not  amiss  to  make  further  suggestions  as  to  the 
work  of  the  Board  of  Medical  Examiners,  for  although  the  Legis- 
lature has  given  them  full  power  to  fix  the  standard  of  qualifica- 
tion and  make  by-laws  governing  their  own  action,  the  elective 
power  in  choosing  these  Boards  is  vested  in  the  North  Carolina 
Medical  Society,  and  the  sentiments  of  the  Society  would  natur- 
ally be  reflected  by  the  Board  chosen. 

It  has  been  and  is  the  custom  to  admit  to  examination  any  and 
all  persons  presenting  themselves.  The  only  requirement  being 
the  easy-to-be-obtained  certificates  of  moral  character,  and  the 
merit  of  having  existed  2t  years.  It  by  any  means  the  applicant 
can  answer  a  certain  percentage  of  questions  propounded,  he 
obtains  a  license  founded  on  the  declaration  that  he  is  found 
qualified  to  practice  medicine  in  all  its  branches. 

In  those  parts  of  the  world  where  the  standard  of  medical 
education  is  highest,  men  are  admitted  to  examinations  only 
after  a  sufficiently  long  training,  not  only  didactically,  but 
clinically  and  in  the  laboratory.  The  mere  correct  answering  of 
a  few  questions  on  a  branch  of  medicine,  regardless  of  antecedent 
practical  training  or  experience,  cannot  be  sufficient  evidence  of 


284  PRESIDENT'S  ADDEESS. 

qualification.  To  obviate  this  difficulty  it  has  been  proposed  to 
have  clinical  examinations.  This  is  hardly  practicable.  Sufficient 
material  of  different  kinds  are  hard  to  obtain.  The  diagnosis  of 
any  given  subject  once  made  would  soon  become  known  to  all, 
and  even  if  the  candidate  failed  in  the  clinical  test,  he  yet  might 
average  the  percent  necessary  to  obtain  license.  An  examina- 
tion which  ignores  the  candidate's  past  as  to  training  would 
require  to  be  long  and  tedious,  especially  if  clinical  and  labora- 
tory features  are  included.  Better,  far,  trust  something  to 
schools  which  are  equipped  for  giving  all  necessary  training 
and  require  all  candidates  for  examination  to  give  evidence 
sufficient  clinical  and  laboratory  experience.  If  the  examining 
Board  have  not  authority  to  regulate  these  matters,  our  law 
ought  to  be  amended. 

Another  matter  of  importance  may  be  harder  to  regulate,  yet 
worthy  of  the  attempt.  Namely  the  interchange  of  courtesies 
between  the  States,  at  least  th(/se  bordering  on  North  Carolina. 
Where  a  sufficiently  high  standard  is  maintained  by  any  State 
Board  its  licentiates  might  very  well  be  admitted  to  other  States. 
It  means  an  unnecessary  hardship,  for  instance,  for  a  physician 
living  on  the  border  of  North  Carolina  and  Virginia  to  have  to 
pass  the  Boards  of  both  States. 

It  may  be  like  the  re-threshing  of  old  straw  to  refer  to  the  im- 
portance of  public  hygiene,  and  the  necessity  of  procuring  legis- 
lation for  the  promotion  of  that  object,  but  as  that  sort  of  straw 
has  yielded  so  comparatively  little  of  the  grain  which  it  is  capa- 
ble of  producing,  I  am  impressed  that  we  should  continue  to 
thresh.  As  far  as  we  are  concerned,  I  do  not  feel  that  it  is  nec- 
essary to  remind  this  body  of  these  things,  much  less  to  offer 
instructions,  but  with  the  people  in  general  as  well  as  their  legal 
representatives  it  is  different.  They  have  not  yet  found  out  the 
best  way  to  spend  their  money  with  the  medical  profession  to 
get  the  best  returns.  With  them,  the  time  honored  function  of 
the  doctor  is  to  apply  remedies  to  diseases,  and  according  to  the 
law  of  supply  and  demand,  the  physician  usually  equips  himself 
for  the  performance  of  that  function,  and  by  solicitation  and 
practice  grows  in  that  direction.  It  is  not  my  purpose  to  dero- 
gate this  part  of  the  physician's  work.  The  world  would  be 
much  poorer  without  the  legitimate  use  of  opium,  chlorcform, 


PRESIDENT'S  ADDKESS.  28q 

cocain,  quinine,  iodine,  mercury  and  other  remedies.  If  the  evil 
is  upon  us,  that  which  removes  or  mitigates  it  will  continue  to 
be  appreciated  and  sought,  but  where  cure  can  save  its  thous- 
ands, prevention  can  save  its  tens  of  thousands,  and  it  is  a  crying 
necessity  to-day  that  this  fact  receive  both  a  thoeretical  and 
practical  realization  by  the  whole  people. 

Before  we  can  hope  to  leaven  the  whole  lump  of  the  body  poli- 
tic let  the  physician  scrutinize  himself  and  the  field  that  he 
occupies,  to  see  how  far  he  is  the  exponent  of  the  true  science,  or 
to  what  extent  he  typifies  or  justifies  a  recent  cartoon  that  rep- 
resents nature  and  disease  in  fierce  combat,  while  the  doctor 
comes  up  blind-folded,  and  with  his  cudgel  strikes  right  and 
left,  now  striking  the  disease  and  now  the  patient. 

The  history  of  the  application  of  therapeutic  measures  (drugs 
mainly)  does  much  to  justify  this  cartoon.  It  is  not  necessary 
to  more  than  refer  to  the  incantations  and  other  absurdities  of 
ignorance  and  superstition  which  were  in  keeping  with  the  dark 
ages  in  which  they  practiced.  Within  the  memory  of  the  men 
of  to-day,  famishing  fever  patients  have  been  deprived  of  water 
by  their  mis-guided  attendants,  who  were  governed  by  tradition 
and  custom,  rather  than  by  the  dictates  of  common  sense,  and 
the  unerring  cravings  of  nature.  Even  the  foul  air  of  the  patient's 
room  was  carefully  confined  by  closing  the  doors  and  windows, 
and  perhaps  his  strength  still  more  reduced  by  copious  blood 
letting. 

My  mother  related  to  me  an  experience  in  her  early  life.  Her 
father  living  on  his  plantation  was  stricken  with  fever,  and  after 
some  days,  or  weeks,  of  bleeding  and  famishing  he  died.  A 
number  of  his  negro  slaves  were  also  stricken  and  under  the 
same  management  went  the  same  way.  One  servant  begged  to 
be  let  alone,  and^not  subjected  to  the  treatment.  His  wishes  were 
gratified  and  he  alone  recovered.  I  remember  the  old  man  well. 
He  lived  to  advanced  age. 

Homeopathy  and  a  number  of  other  pathies,  in  spite  of  their 
absurdities,  had  fruitful  soil  in  which  to  grow.  They  were  less 
aggressive  on  the  persons  of  the  suffermg  sick,  and  if  they  gave 
no  aid,  were  not  so  likely  to  hinder  natural  recoveries,  and  so 
the  regular  profession  looked  on,  learning  from  experience,  grew 
in  knowledge,  by  its  natural  evolution,   and  became  wiser  than 


286 


PRESIDENT'S  ADDRESS. 


their  critics.  But  the  medical  millennium  has  not  yet  come,  nor 
are  the  days  of  mal-practice  past.  Even  among  operative  pro- 
cedures, the  fads  of  gynecologists  and  the  exploits  of  those  seek- 
ing fame  by  startling  measures  in  other  fields  require  constantly 
to  be  challenged,  to  show  cause  why  they  should  not  be  discontin- 
ued. If  the  novice  takes  up  an  optimistic  modern  work  on  materia 
medica,  and  studies  the  physiological  effect  of  drugs  and  their 
therepeutic  application,  he  might  easily  be  impressed  with  the 
belief  that  drugs  could  control  every  pathological  process,  and 
remove  every  morbid  condition.  Coupled  with  these  studies,  he 
is  very  much  surprised  to  find  that  works  on  practice  of  medicine 
(perhaps  especially  those  of  the  scientific  Germans)  will  give  ex- 
haustive descriptions  of  disease,  pathology,  etiology,  clinical 
history,  diagnosis,  and  prognosis,  but  beyond  general  reference 
to  hygiene,  nothing  specific  as  to  the  treatment.  The  fact  of 
the  limited  power  of  drugs  to  work  beneficial  changes,  begins 
to  dawn  upon  him,  and  that  even  those  that  are  of  undoubted 
value  are  like  edged  tools,  and  require  careful  handling.  Even 
ourcomparatively  harmless  quinine,  which  so  effectually  destroys 
the  malarial  plasmodium  has  been  made  to  do  its  share  of  harm. 
On  no  less  authority  than  the  German  professor,  Leibermeister, 
40  grains  at  a  dose  have  been  given  to  typhoid  patients.  Within 
recent  years  the  cold  tar  antipyretics  were  hailed  with  delight. 
Fever  killers  had  come  at  last!  A  Baltimore  professor  told  his 
class  that  antipyrine  was  what  he  had  been  praying  for.  I  think 
you  will  agree  with  me  that  more  patients  than  fevers  have  been 
killed  by  them;  and  these  remedies  are  in  rather  common  use 
among  the  laity. 

Not  many  days  ago  I  visited  a  child  to  whom  the  mother  had 
administered  a  dose  of  acetanilid  before  the  cold  stage  of  an  in- 
termittent fever  had  disappeared.  Alarming  symptoms  followed. 
Another  case  came  under  my  notice,  where  a  farmer  had  ad- 
ministered a  dose  of  acetanilid  under  similar  circumstances. 
The  child  died,  apparently  from  its  effects. 

Not  many  years  ago,  the  doctrine  was  promulgated  that  dis- 
ease, a  condition  of  lowered  vitality,  required  to  be  com  batted 
by  copious  administration  of  alcoholics.  This  fascinating  theory 
had  many  adherents,  and  did  much  harm.  In  the  field  of  dietet- 
ics,   we    went   from   starvation   to   stuffing.      Even    to-day   an 


PRESIDENT'S   ADDRESS.  287 

American  text  book  advises  that  a  typhoid  fever  patient  may  take 
as  much  as  six  quarts  of  milk  a  day,  a  quantity  that  has  been 
shown  by  physiological  experiment  to  be  one-third  more  than 
the  full  digestive  capacity  of  a  healthy  man,  eating  nothing  else 
and  digesting  all  the  day.  We  have  no  infallible  guides.  Our 
reason  must  challenge  every  theory,  and  our  experience  prove 
all  things,  and  hold  fast  to  that  which  is  good. 

But  why  this  arraignment  of  a  profession,  which  in  the  matter 
of  education,  conscientiousness  and  faithfulness  compares  favor- 
ably with  any  on  earth.  It  is  to  lament  that  our  most  uncertain 
and  dangerous  functions  are  most  in  demand;  that  millions  of 
dollars  are  paid  by  the  people  for  the  practice  of  medicine  as  it 
is  being  done,  and  as  to  some  little  extent  has  been  indicated  in 
the  foregoing  pages,  while  our  best  functions  or  capabilities  are 
dwarfed  by  disuse  and  neglect.  The  public  health  officei  would 
have  to  be  a  missionery  at  his  own  expense,  while  a  premium  is 
put  on  disease.  This  is  not  a  mere  perverse  and  unnatural 
choice  of  the  people.  They  are  as  wise  as  we  are,  and  will 
seek  their  own  good  as  they  conceive  it  to  be-  We  are  of  them, 
and  differ  only  as  regards  these  matters  in   knowledge. 

li  they,  the  masses  ot  the  people,  knew  as  much  of  the  sources 
of  the  disease  as  the  educated,  better  element  of  physicians,  who 
do  you  suppose  would  be  in  the  van  of  the  procession  to  stamp 
it  out?  The  man  who  reaps  a  harvest  when  disease  runs  riot  or 
the  man  who  pays  the  bills?  That  the  people  should  become 
possessed  of  this  knowledge  is  the  prime  requisite,  for  should  we 
obtain  such  legislation  as  in  our  judgment  was  all  that  was  nec- 
essary, and  such  appropriations  as  would  leave  our  Board  of 
Health  unhampered  in  the  discharge  of  their  functions,  the  laws 
would  be  largely  inoperative  if  lacking  in  popular  sympathy  and 
support ;  besides  many  of  these  things  would  depend  on  habits  of 
individuals  which  legislation  could  not  control.  It  is  to  be, 
then,  chiefly  a  matter  of  education ;  and  how  to  accomplish  this, 
is  the  problem. 

If  the  individual  physician  in  his  professional  and  social  con- 
tact with  his  clients  sows  the  seed,  if  our  Boards  of  Health, 
local  and  State,  continue  and  even  improve  upon  their  good 
work,  and  if  our  schools  from  the  lowest  to  the  highest  teach 
the  rudiments  of  the  science  of  health,  and  unfold  to  the  mind 


288  PRESIDENT'S  ADDRESS. 

of  the  pupil  the  necessity  of  expert  work  in  the  prevention  of 
disease,  knowledge  must  grow.  And  if  our  State  Society,  in  its 
organized  capactity,  with  the  courage  of  its  convictions,  does 
not  hesitate  to  urge  necessary  legislation,  they  will  have  dis- 
charged their  duty,  and  may  saon  accomplish  much. 

Typhoid  fever,  which  is  perhaps  entirely  preventable,  causes 
the  State  the  loss  ol  many  a  victim  and  much  treasure.  Cur- 
rent knowledge  or  opinion  ascribes  its  propagation  almost  en- 
tirely to  intestinal  discharges  of  the  infected.  Prevention  would 
seem  to  be  in  easy  reach,  yet  it  goes  on.  Personal  observation 
leads  me  to  believe  that  disinfection  of  the  dejections  is  net  ac- 
complished in  one  half  the  cases.  Many  cases  of  continued  fever 
are  not  considered  typhoid  fever,  which  are  most  likely  of  that 
nature.  I  will  not  discuss  the  subject,  but  pass  it  by  with  the 
recommendation  that  the  dejections  of  all  fever  patients  be  dis- 
infected. The  public  should  be  instructed  to  do  so,  even  where 
physicians  are  not  employed,  as  they  often  are  not,  and  it  may 
be  a  fit  subject  for  compulsory  legislation.  Our  Board  of  Health 
has  done  a  good  service  in  the  matter  of  prevention  of  malarial 
fevers  by  use  of  deep  well  and  cistern  water.  But  a  properly 
managed  cistern  is  an  exception.  Infectious  germs  are  carried 
from  the  atmosphere  or  house-tops  to  the  cistern.  Filters,  often 
imperfect,remain  unchanged,  until  oversaturated.  They  become 
thus  the  source  of  infection.  Tuberculosis  continues  to  be  pro- 
pagated by  the  expectoration  of  the  infected  without  hindrance, 
except  perhaps  in  one  municipality  in  the  State.  Milk  is  sold 
from  any  kind  of  cow  which  will  afford  it.  Diseased  meats  are 
sold  in  the  markets.  Ice  is  imported  from  impure  sources  and 
people  believe  that  freezing  purifies  it,  which  is  true  only  to 
a  limited  extent,  and  may  be  manufactured  from  impure  water. 
Any  kind  of  canned  food  is  sold  that  any  one  will  buy.  There 
is  HO  check  on  adulteration  or  fraud  as  to  what  the  people  eat  or 
drink  or  take  as  medicines,  patent  or  proprietary,  save  their  own 
unskilled  judgment,  warped  or  blinded  by  alluring  advertise- 
ments and  unblushing  false  asseitions. 

The  physician  often  finds  that  a  patient  unable  to  pay  him  has 
raked  up  money  enough  to  pay  an  exorbitant  price  for  worth- 
less medicines  or  appliances.  Druggists  practise  medicine. 
Spectacle  venders,   ignorant  or  unscrupulous,  still  practice  this 


preside;^t-s  address.  280 

branch  of  the  medical  art,  though  a  medical  college  graduate 
has  first  to  pass  our  State  Board.  -  Dangerous  drug  habits  or 
other  evil  consequences  arise  from  headache  cures  and  the  like. 
Beverages  (coca  cola  for  instance)  sold  from  the  soda  fountains 
should  be  subject  to  analysis  and  the  people  advised,  or  the  sale 
interdicted  if  necessary.  I  refrain  from  further  specific  refer- 
ences. 

The  doctor  of  the  future  will  probably  differ  more  widely 
from  the  one  of  to- day,  than  the  doctor  of  to-day  differs  from 
the  one  of  the  past.  We  know  something  of  him  of  the  past  and 
present  and  that  the  tares  have  been  mixed  with  the  wheat  in 
varying  proportions.  With  prophetic  eye  we  may  contemplate 
him  of  the  future,  but  we  know  not  how  fa/r  distant,  or  how  near 
at  hand.  The  poet  or  philosopher  may  by  inspiration  point  the 
way;  the  scientist  by  experimental  research  may  demonstrate; 
still  events  occur  only  in  the  fulness  of  time,  or  that  period  in 
the  evolution  of  the  human  race,  under  the  sovereignty  of  God, 
when  it  is  possible  to  achieve  that  which  before  was  not  attain- 
able, but  the  sword  of  the  doctor  (his  weapons  of  warfare  on 
disease  or  the  diseased)  will  be  changed  to  the  pruning  hook, 
which  cuts  away  the  poisonous  branches  upon  which  grows  the 
deadly   fruit. 

In  the  propagation  of  the  race,  in  the  construction  of  human 
habitations,  in  clothing  and  in  food,  in  labor  and  in  recreation 
there  is  a  rational  wisdom,  and  in  connection  with  these  there 
should  be  skilled  advisers.  If  physic  should  be  thrown  to  the 
dogs,  will  the  doctor's  occupation  be  gone?  Not  when  he  has 
proper  surveillance  over  everything  that  affects  the  health  of 
people.  In  his  present  status  of  equipment  he  could  do  much 
more  than  he  does  or  is  permitted  to  do,  but  when  the  new  order 
of  things  creates  the  demand,  medical  colleges  will  not  condone 
ignorance  of  chemistry  and  physics  even  as  now  imperfectly 
taught,  nor  make  side  shows  of  the  microscope  and  laboratory. 
These  stones  which  are  well  nigh  rejected  by  the  builders  of 
medi  ;al  education  will  become  the  heads  of  the  corner.  These 
things  will  be  sine  qua  noii. 

North  Carolina  has  been  called  the  Rip  Van  Winkle  of  States; 
still  she  has  been  known  to  arouse  from  her  lethargy.  In  the 
matter  of  legislation  regulating  the  practice  of  medicine,   she 


2 go  ANDERSON-ANNUAL   OKATION. 

was  (through  the  influence  of  our  S  )ciety)  in  the  van  of  the  pro- 
cession. And  in  this  historic  city,  (Mecklenburg  County)  May 
2oth,  1775,  she  sounded  the  bugle  call  as  a  pioneer  of  liberty.  It 
is  fitting  that  we  should  here  resolve  to  push  still  further  the 
lines  of  human  progress. 


ANNUAL  ORATION. 


TWO    SOUTHERN    PIONEER    HEROES    IN    SURGERY 
AND  GYNECOLOGY.* 

By  Albert  Anderson,  M.D.,  Wilson,  N.  C. 


Mr.   President  and  Gentlemen  of  the  N.  C.  Medical  Society: 

DECADE  after  decade  it  has  been  asserted  that  North  Caro- 
lina is  the  Rip  Van  Winkle  State.  I  deny  the  charge. 
Of  all  places  in  the  world  this  is  the  most  appropriate  to 
make  the  denial.  We  are  upon  historic  ground.  It  is  well  to 
remember  to-night  that  we  tread  soil  ot  the  nativity  of  Aineri- 
can  liberty.  Upon  the  soil  of  old  Mecklenburg  was  born  the 
Declaration  of  Independence  more  than  fourteen  months  before 
that  immortal  document  was  produced  at  Philadelphia.  The 
heroes  of  this  county  in  convention  assembled  declared  in  thun- 
dering tones  those  great  principles  of  personal  liberty  and 
American  independence  which  have  become  the  foundation  and 
tower  of  human  rights  throughout  Christendom.  In  thunder- 
ing tones,  I  said,  and  remember  that  the  roar  of  thunder  is  born 
in  the  flask  of  lightening.  May  20,  1775,  there  flashed  forth 
from  the  immortal  soul  of  Dr.  Ephraim  Brevard  this  declara- 
tion :  "Let  us  declare  our  independence  and  defend  it  with 
our  mntual  honor."  This  came  from  a  crowd  "neither  sleepy, 
hungry  nor  fatigued. " 

The  seven  revolutionary  engagements  fought  within  forty 
miles  of  this  beautiful  city  vindicated  the  heroism  of  this  daring 
deed,  and  eternally  established  the  right  of  this  place  to  be 
called  the  "Hornets'  Nest"  of^the  Revolution.  It  -nakesagreat 
difference  to  the  force  of  any  sentence  whether  there  be  a  man 
behind    it  or  not.      Through   every   word,    every   clause,   every 


ANDERSOM- ANNUAL   ORATION.  ^oi 

sentence  of  that  Mecklenburg  Declaration,  we  meet  the  eye  of 
the  most  determined,  heroic  man.  Their  force  and  terror  inun- 
date every  word;  the  commas  and  dashes  are  alive;  the  writing 
is  athletic  and  nimble.  It  went  far — is  going  to-day — will  live 
forever  and  travel  to  the  world's  remotest  bounds.  Great  patri- 
otic doctor!  We  honor  thee  to-night  as  the  chieftest  lover  of 
thy  country.  Thy  single  eye  saw  political  truth;  thy  intelli- 
gence foimulated  it,  and  thy  courageous  hand  penned  words 
embodying  our  inalienable  rights,  which  are  but  the  transcript 
fiom  the  will  of  God.  Thy  patriotism  bore  the  fruits  of  union, 
domestic  tranquility,  justice,  liberty  and  welfare. 

Here,  too,  was  the  home  for  a  long  time  of  North  Carolina's 
greatest,  wisest,  purest  statesman.  Like  Ephraim  Brevard  he 
died  with  a  single  physical  eye,  typifying  the  great  ruling  pur- 
pose of  his  life's  work,  to  serve  the  best  interest  of  his  beloved 
people.  In  peace,  war  or  imprisonment,  he  was  first  and  most 
loved  of  all.  North  Carolina  never  had  any  honor  too  great,  any 
love  too  precious  to  give  their  first  citizen  and  greatest  states- 
man— Zebulon  Baird  Vance. 

There  are  common  traits  that  mark  heroes  wherever  you  find 
them,  under  all  claims,  in  every  profession.  Take  the  medical 
or  surgical  hero.  He  maintains  his  equilibrium.  He  always 
rides;  is  not  reduced  to  dismount  and  walk,  because  his  passions 
are  running  off  with  him  in  some  distant  direction.  '"Calm  and 
serene"  amidst  the  lightning's  fiash  or  the  thunder's  roar,  the 
tumult  and  uproar  of  the  howling  mob,  or  the  terror  and  excite- 
ment of  home.  After  the  smoke  of  battle  has  cleared  away, 
there  is  no  trouble  to  the  dullest  vision  in  seeing  victory  flashing 
from  his  eye.  "Will  he  never  come?"  she  cries,  an'  a'  heard  the 
soond  o'  the  horses  feet  on  the  road  a  mile  awa'  in  the  frosty  air. 
The  doctor  comes  skelpin  into  the  close,  the  foam  fleeing  frae 
his  horse's  mouth.  Whar  is  he?  wes  a'  that  passed  his  lips  an' 
in  five  meenuis  he  hed  him  on  the  feeding  board  and  wes  at  his 
work-sic  work,  neeburs, — but  he  did  it  weel.  An'  ae  thing  a' 
thocht  rael  thouchfu'  o'  him,  he  first  sent  the  laddie's  moither  toe 
get  a  bed  ready.  It  was  mighty  tae  see  him  come  intae  the  yaird 
that  day,  neeburs;  the  vera  look  o'  him  was  victory."  This 
William  McClure  was  an  ideal  type  of  a  hero.  We  have  some 
in  North  Carolina.      Like   McClure  they    "do  their  best  for  the 


202  ANDERSON— ANNUAL  ORATION. 

need  of  every  man,  woman  and  child  in  their  wild  straggling 
districts,  year  in,  year  out ;  in  the  snow,  in  the  heat ;  in  the  dark, 
in  the  light;  without  rest  or  holiday  for  forty  years,"  and  the 
very  sight  of  them  is  victory. 

Is  the  physician  always  brave  enough  to  stand  by  his  patient 
when  the  laity  see  in  the  form  of  convulsions  the  death  angel 
coming  with  rapid,  but  sure  speed — when  the  cries  come  quick 
and  loud  for  help!  help!!  help!!!  At  such  times  a  hero  "with 
a  military  attitude  of  soul  affirms  his  ability  to  cope  single  handed 
with  the  infinite  army  of  enemies"  and  thereby  emulates  the 
example  of  the  great  physician  when  he  stepped  out  upon  the 
turbulent  waters  and  said  "peace  be  still." 

There  are  other  foes  than  external  that  a  doctor  must  meet 
and  conquer, — those  of  his  own  nature.  To  cope  with  these  he 
must  have  a  will  that  says,  "Thus  far  and  no  tarther. "  When 
did  you  yield  to  the  clamoring  demands  of  a  patient  for  more 
opium  or  whiskey?  Then  it  was  you  who  played  the  part  of  a 
coward.  Such  cowardice  in  pandering  to  damning  appetites  is 
retroactive  and  damns  the  doctor  with  short  patronage,  supreme 
contempt  and  the  habit  itself. 

"Vice  is  a  monster  of  so  frightful  mien, 
As  to  be  hated,  needs  but  to  be  seen, 
But  seen  too  oft,  familiar  with  his  face. 
We  first  endure,  then  pity,  then  embrace.'' 
"Cleave  to  the  right  as  a  ladder   that   leads   up    to    manhood 
and   God." 

Let  us  not  forget  results  which  science  teaches.  "In  the 
shipwreck  only  the  pilot  chooses  with  science  the  means  of  escape, 
he  whocomestoland  mustsail  with  him."  There  is  a  secret  impulse 
in  every  character.  Obey  it,  tho'  the  heavens  fall  and  the  earth 
swings  from  beneath  your  feet.  We  ought  to  know  from  ex- 
perience, observation  and  science  the  things  to  touch  not,  taste 
not  and  handle  not.  Yet  in  the  face  of  this  triple  vantage 
ground,  is  it  a  fact  that  to  our  numbers  we  have  the  largest  per 
cent,  of  any  other  class  that  takes  whiskey  and  morphine  as  a 
panacea  for  our  restoration  to  rest  and  health?  Insomnia  comes 
to  our  couch;  sleep  we  must  have  in  order  to  work.  If  trional 
is  not  a  sufficient  hypnotic,  morphine  is,  and  too  often  the  arms 
of  Morpheus  enclose  us  in  his  sweet  but  fatal  embraces.  It  is 
appropriate  now  to  sound  this  note  of  duty.      Put  on  the  armor 


ANDERSON- ANNUAL  ORATION.  20  t 

of  manhood.  Teach  by  example  as  well  by  precept.  No  man 
can  fill  the  place  of  a  hero  in  our  ranks  who  does  not  check  the 
ordinary  evil  propensities  of  his  own  nature. 

Take  the  father  of  gynecology, — J.  Marion  Sims.  Test  the 
material  out  of  which  he  was  made.  He  was  patient  and  per- 
sistent. He  carried  the  plans  of  his  powerful  mind  into  minute 
details,  manipulating  with  that  skillful  hand  to  a  hair's  point, 
finishing  every  step  as  carefully  as  if  he  were  going  to  receive  a 
fortune  at  once.  Without  encouragement,  at  one  time  without 
friends,  without  money  and  without  health,  the  hero  worked  on 
till  victory  was  his.  The  heroic  mould  of  this  man  will  bear  the 
scrutiny  of  the  solar  microscope. 

•'Slave  to  no  secret,  who  took  to  private  road, 
But  looked  through  Nature  up  to  Nature's  God." 

His  nature  opened  a  foreground  in  the  medical  world,  and 
like  the  breath  of  morning  landscapes,  invited  his  comrades  on. 
The  conditions  that  met  this  pioneer  have  always  existed.  Sur- 
geons had  looked  on  and  declared  by  their  inactivity  and  non- 
intereference  that  it  was  impossible  to  remedy  the  miserable  ex- 
istence. After  efforts  lasting  four  years,  doing  the  operation 
thirty  times  on  one  patient,  "with  palpitating  heart  and  anxious 
mind,  he  found  on  removing  the  stitches  a  perfect  union  of  the 
little  fistula."  Our  hero  broke  the  unbiblical  cord  that  holds  so 
many  of  us  to  nature  and  rose  to  the  platform  of  pure  genius 
and  has  ever  since  received  the  gratitude  of  thousands  of  women 
restored  to  health  through  his  discovery  and  work.  He  did  not 
peer  into  the  future  for  some  nicke  in  the  tenaple  of  fame  where 
his  name  would  be  placed,  but  did  his  work  perfectly,  patiently, 
without  reward  or  hope  of  reward.  Thus  it  is  ever  with  a 
true  man.  "That  which  a  man  feels  intensely,  he  struggles  to 
speak  out  of  himself,  to  see  represented  before  him  in  visual, 
shape" — with  a  kind  of  life  and  historical  reality  in  it.  With  Sims 
it  was  a  most  earnest  thing  to  be  alive  in  the  world.  The  occa- 
sion of  woman  being  thrown  from  her  pony  furnished  him  with 
the  opportunity  of  inventing  his  speculum.  A  vista  of  wonder- 
ful possibilities  was  opened  to  his  inquiring  mind.  He  saw  re- 
sults giving  to  woman  relief  and  happiness  that  thrilled  him. 
"A  hero  is  a  hero  at  all  points,  in  the  soul  ind  thought  of  him 
first  of  all."  Like  truth,  tho  crushed  to  earth,  he  rose  after 
every  failure.      He  did  not  complain  at  nature  and  hold  her  re- 


2Q.  ANDERSOM— ANNUAL   ORATION. 

sponsible  for  his  failures.  His  work,  not  nature,  was  considered 
at  fault.  Eliminating  first  one  factor  and  another  that  prevented 
his  success  till  the  darkest  hour  came,  and  like  the  last  hour  be- 
fore dawn — so  the  dawn  soon  came  to  his  professional  work,  and 
he  cried  "Eureka."  Success  followed  success  till  there  wus  no 
man  or  surgeon  above  him  in  honor  or  skill.  In  his  trials,  fail- 
ures, successes,  honors  and  fame,  we  alwaj^s  find  him  a  great 
soul,  loyally  submissive,  reverent  to  Him  who  is  above.  Had  he 
followed  the  advice  of  his  brother  in  law,  "to  resign  the  whole 
subject  and  give  it  up"  he  would  not  have  been  the  father  of 
gynecology,  the  founder  of  the  Woman's  Hospital  in  New  York, 
and  the  recipient  of  honors  and  honorariums  of  kings,  queens; 
emperors,  empresses;  princes,  princesses.  When  John  Hancock 
signed  his  name  to  the  Declaration  of  American  Independence, 
it  was  said  that  he  wrote  his  signature  in  letters  so  large  and  so 
loud  that  the  cry  for  liberty,  which  they  represented,  was  heard 
around  the  world.  With  equal  truth  it  has  been  said  that  when 
Marion  Sims  fell  so  suddenly  into  the  arms  of  death,  the  shock 
was  felt  wherever  woman  suffers  or  surgery  is  practised.  (Had 
this  been  said  of  Ephraim  Brevard  instead  of  John  Hancock,  it 
would  have  been  the  whole  truth.) 

When  thinking  of  the  daring  deeds  of  heroism  in  surgery, 
we  naturally  and  with  pleasure  turn  our  thoughts  to  those  ac- 
complished by  southern  heroes,  and  for  good  reasons,  because 
they  are  unexcelled  in  skill  and  ability  by  men  at  any  other  point 
of  the  compass.  With  thrilling  delight  we  mention  another  hero 
in  the  surgical  galaxy  of  the  deathless  the  Father  of  Ovariotomy, 
Ephraim  McDowell,  of  Danville,  Ky.  This  fatherhood  is  99  years 
of  age  next  December  13th.  The  result  of  this  parentage,  I 
should  say  from  the  best  obtainable  statistics,  is  the  addition  of 
'over  fifty  thousand  years  to  the  life  of  woman.  Such  a  treme- 
dous  boon  to  woman  comes  from  inspiration,  skill  and  heroism. 
He  was  born  not  to  die  to  surgery.  He  is  also  immortal  in  the 
moral  and  spiritual  spheres.  Long  and  faithfully  had  he  studied 
the  possible  success  of  ovariotomy  when  his  first  subject  came 
under  his  professional  eye.  After  a  most  thorough  and  critica' 
examination  Dr.  McDowell  informed  his  patient,  a  woman  of 
unusual  courage  and  strength  of  mind,  that  the  only  chance  for 
relief  was  the  removal  of  the  diseased    mass.      He  explained   to 


ANDERSON -ANNUAL  ORATION.  -„- 

29:) 
her  with  great  clearness  and  fidelity  the  nature  and  hazard  of 
the  operation.  He  told  her  he  had  never  performed  it,  but  that 
he  was  ready,  if  she  was  willing,  to  undertake  it  and  to  risk  his 
reputation  on  the  issue,  saying  it  was  an  experiment,  but  one 
well  worthy  of  trial.  A  hero  and  a  heroine  had  met.  Unlike 
FeJix  to  Paul,  she  listened  and  was  fully  persuaded.  His  life 
hung  on  the  recovery  of  this  heroic  woman.  The  mob  led  by 
the  profession  (shame  be  it  said)  would  have  put  an  end  to  this 
heroic  life  had  this  woman  diel.  But  with  confidence  in  God 
and  in  his  own  ability,  he  dared  to  do  and  if  necessary  to  die  to 
save  this  woman's  life.  No  anaesthetic  to  wrap  into  insensi- 
bility the  quivering  nerves  of  his  subject — "Only  a  covering 
thrown  over  her  pallid  face  to  shut  from  view  the  flashing  of  the 
instruments  used.  The  operation  was  done,  the  woman  lived. 
The  result  was,  is,  and  ever  will  be,  the  greatest  boon  hitherto 
to  woman  and  an  eternal  inheritance  to  surgery. 

Just  prior  to  this  operation  he  communed  with  his  God.  That 
prayer  of  the  immortal  McDowell  was  the  true  index  of  his  na- 
ture. His  purpose  was  strong  as  Gibraltar.  His  conception  of 
the  operation  was  clear  as  the  noon-day.  To  relieve  suffering 
by  surgical  means  was  an  uncontrollable  purpose.  Do  you  sup- 
pose for  a  moment  that  he  considered  the  effect  of  the  operation 
upon  his  success — whether  it  would  enlarge  his  inflnence  among 
the  laity  or  make  his  name  immortal  to  the  profession?  Ufility 
only  thrilled  him,  the  relief  of  a  woman  moved  him  to  action. 
"Let  a  man  do  his  work;  the  fruit  of  it  is  the  care  of  another." 
Are  not  all  true  doctors  that  live  or  that  have  lived,  "soldiers  of 
the  same  army  enlisted  under  heaven's  captain  and  to  do  battle 
against  the  same  enemies?"  Kphraim  McDowell,  triple  immortal 
spirit,  we  hail  thee  as  hero,  christian  and  chiefest  surgeon  of 
thy  day  the  world  over. 

.  The  work  and  words  of  these  pioneer  heroes  are  the  richest 
fruitage  we  possess  to  day.  Out  of  the  depths  of  their  souls 
sprang  deeds  immortal.  To  every  loyal  son  of  ^Esculapius  they 
are  brothers. 

"On  one  occasion  an  orator  was  contrasting  the  fame  of  states- 
men, orators  and  military  men,  and  said  he,  chief  among  all 
these  is  he  who  bears  the  mark  of  our  guild,  Ephraim  McDowell. 
For  the  labors  of  the  statesmen  will   give   away   to   the   pitiless 


2n6  ANDERSON— A^TNUAL  ORATION. 

logic  of  events,  the  voice  of  tlie  orator  grew  fainter  in  the  com- 
ing ages  and  the  deeds  of  the  soldiers  eventually  find  place  only 
in  the  library  of  the  studeut  of  military  campaigns;  Vv^hile  the 
achievements  of  the  village  surgeon,  like  the  widening  waves  of 
the  sea,  shall  reach  the  remotest  shores  of  time."  Verily  the 
achievements  of  these  heroes  prove  the  truth  of  this  beautiful 
contrast.  These  two  were  rural  surgeons.  We  should  take  en- 
couragement from  the  history  of  these.  We,  as  they  did,  live 
away  from  medical  centers  in  small  towns  and  rural  districts. 
Such  places  have  grown  men  who  have  given  to  the  world  the 
most  practicable  discoveries  and  advances  in  surgery,  medicine 
and  hygiene.  These  are  too  numerous  to  mention,  but  they 
have  erected  in  all  ages  their  monuments,  imperishable  and 
eternal.  '^It  is  said  that  the  ploughman,  tilling  the  fields  of  the 
western  slope  of  our  continent,  who  keeps  his  eyes  intently  on 
the  furrow,  may  occasionally  find  nuggets  of  gold;  so  the  faith- 
ful toiler  amidst  human  ills  is  liable  to  unearth  jewels  of  fact, 
which  garnered  and  recorded,  will  add  to  the  wealth  of  surgical 
knowledge."  Sims  and  McDowell  kept  their  eyes  intently 
upon  their  work.  They  recorded  only  a  fraction  of  their  dis- 
coveries; yet  they  kept  a  sufficient  record  to  render  themselves 
deathless  and  their  facts  invaluable.  "The  spirits  of  great  men, 
like  immortal  ships,  sail  the  ocean  of  time,  bearing  treasures  of 
the  civilization  which  gave  them  birth.  They  outride  the  fury 
of  all  the  storms  and  will  sail  on  till, 

"The  stars  grow  old, 

The  sun  grows  ^old, 

And  the  leaves  of  the  Judgment  Book  unfold." 
"Their  day  is  done;  their  sun  is  set.  But  from  the  scene  of 
its  setting  there  streams  up  a  trailing  brightness — the  shining 
example  of  those  who,  while  profound  in  silence,  wise  in  counsel 
and  excellent  in  skill,  were  also  sincere  in  piety,  true  in  friend- 
ship and  genial  in  intercourse.  Their  presence  entered  the  sick 
chamber  like  a  sunbeam  from  heaven  streaming  into  a  darkened 
room.  Its  mild  radiance  lingers  in  hundreds  of  homes  and 
thousands  of  hearts.  They  burn  as  pure  stars  fixed  in  the  sur- 
gical firmament,  at  which  the  great  and  high  of  all  ages  kindle 
themselves." 


SOME  REFLECTIONS  ON  POST-GRADUATE  INSTRLX- 
TION.* 

By  C.  E.  Moore,  M.  D.,  Wilson,  N.  C. 


AT  your  request  I  have  departed   from  the  usual  custom  of 
presenting  a  paper  on  some  special  medical  subject  and 
have  selected  as  a  topic  for  my   running  remarks,  "Some 
reflections  on  Post  Graduate  Instruction." 

As  this  was  my  first  visit  to  the  great  city  of  New  York  where 
multitudes  of  rushing  humanity  throng  the  crowded  avenues 
and  your  enquiring  eyes  meet  only  the  gaze  of  passing  strangers, 
you  can  imagine  my  security  of  thought  and  feeling  when  I 
realized  I  had  the  pleasureable  companionship  of  my  colleague 
Dr.  M.  and  also  that  of  my  former  classmate  Dr.  J.  With  such 
pleasant  environments  of  social  confreres  I  was  permitted  at 
once  to  enter  the  amphi-theatre  of  medical  instruction,  and  with 
a  sense  of  personal  security,  they  would  assist  in  eliminating  an 
over  dose  of  the  toxines  and  ptomains  of  new  ideas  and  assist 
me  in  digesting  and  assimilating  only  such  thought  as  was  con- 
ducive to  healthy  medical  growth.  Not  expecting  to  become  a 
specialist  in  the  short  space  of  three  weeks,  but  wishing  to  ap- 
propriate whatever  good  there  might  be  in  Zion  I  took  out  a 
general  ticket  which  admitted  me  to  all  the  departments  from 
which  I  might  gather  some  facts  and  ideas  serviceable  to  the 
practitioner.  Perhaps  the  first  thing  that  impresses  one  about 
the  city  doctor  is  his  personel;  his  tidy  dress,  his  animated 
freshness,  his  physical  vigor,  his  courteous  manner  and  his 
deliberate  positive  manhood.  You  again  notice  on  early  stage 
of  your  acquaintance  his  educational  qualifications  and  are  at 
once  impressed  with  the  scholastic  mind  training  he  has  received 
in  addition  to  his  medical  studies.  'Tis  true  his  habitation  and 
environments  are  responsible  foi  this — nevertheless  'tis  true,  and 
places  him  at  a  decided  advantage  over  his  less  fortunate  col- 
leagues. Who  is  it  could  not  win  position,  if  blessed  with  strong 
physique  strengthened  by  scholastic  training  and  literary  at- 
tainments, with  the  best  medical  advantages  at  home  and  abroad 
with  no  special  thought  as  to  livelihood  since  poveity  and  want 
*Read  before  the  Medical  Society  of  Wilson,  N.  C,  ~ 


2gJ  MOORE-POST-GRAEUATE  INSTITUTIONS. 

are  unknown  factors  in  his  household?  The  institutions  in  New 
York,  for  Post  Graduate  Instruction  are  well  equipped  buildings 
with  every  convenience  and  comfort  for  the  student  body,  and 
supplied  with  abundant  clinical  material  that  is  readily  accessi- 
ble to  all  who  may  desire  closer  investigation.  To  do  effective 
work  in  physical  diognosis  ot  the  eye,  ear,  nose  and  throat  each 
student  must  provide  himsel  fwith  necessary  suitable  instruments 
as  none  of  these  are  furnished  there  and  without  them  you  are 
denied  privileges  you  would  otherwise  have. 

The  great  majority  of  all  diseases  were  regarded  as  either 
syphilitic  or  tubercular  and  where  no  history  of  the  former  could 
be  had  it  was  classified  under  the  broad  head  of  tuberculor,  and 
treatment  directed  accordingly.  Medicines  are  not  used  with 
the  same  lavish  hand  that  we  dispense  them,  the  dominating  idea 
being  constitutional  reconstructive  agents  with  good  h3'giene» 
and  leave  the  rest  to  nature.  I  saw  quinine  prescribed  only  one 
time,  that  a  case  of  intermittent  fever,  and  the  method  of  ad- 
ministration being  somewhat  different  from  ours  I  give  it  for 
your  consideration.  Fifteen  grains  bisulph  quinine  every  night 
at  bedtime  and  Warburg's  Tr.  every  morning  before  breakfast; 
give  this  for  6  days  and  then  give  as  a  tonic, 

Fowler's  Solution 3  i 

Tr.  Cinchonadine 

Tr.    Eucal5'^ptus         .      .     .      .      .     aa   3  i 

Sig — 20  drops  3  times  a  day. 
Just  at  this  point  I  would  remark  that  my  impression  is  we 
give  too  much  quinine  in  our  section,  that  is  we  are  too  prone 
to  regard  malaria  as  the /o/is  ei  erigo  of  all  our  disorders  and 
as  a  result  quinine  becomes  one,  if  not  the  chief,  component 
part  of  our  therapeutic  remedies.  I  do  not  wish  to  say  one  word 
of  unkind  criticism  against  the  value  of  quinine  in  malaria;  its 
utility  is  recognized  and  unquestioned,  its  virtues  are  known  to 
every  creed  and  nation  of  civilized  people  and  and  its  potentive 
value  has  builded  for  itself  a  monumental  fame  upon  every  sea 
and  shore.  But  it  is  a  question  if  the  idea  ot  malarial  compli- 
cation has  not  grown  upon  us,  to  the  exclusion  of  other  maladies 
which  a  thorough  and  scier  tific  investigation  would  demonstrate. 
I  believe  this  to  be  a  fact  and  not  a  fancy,  and  while  I  do  admit 
the  great  prevalance  of  malaria  in  its  multiform    complications, 


MOORE-POST-GKADUATE  INSTITUTION.  , 

3^et  I  also  believe  it  oftentimes  serves  as  the  mysterious  hiding 
place  of  our  ignorance  or  proper  appreciation  of  the  true  patho- 
logical condition.  I  noticed  with  a  keen  sense  of  interest  their 
management  of  diseases  of  children,  their  constant  aim  to  pro- 
voke a  smile  from  outraged  nature,  their  presist«nt  effort  by 
dietary  and  hygenic  surroundings  to  so  imitate  the  ways  and 
means  of  nature  that  the  greater  part  of  the  medicinal  treatment 
was  reduced  to  a  minimum.  But  this  is  nothing  new,  we  all 
appreciate  its  truth  but  are  too  timid  to  apply  it,  fearing  unless 
we  keep  baby  on  a  goodly  supply  of  mixtures  and  powders  we 
receive  the  condemnation  of  the  family  or  perchance  the  criticism 
of  the  neighboring  physician.  I  suppose  you  could  find  docto-'s 
(but  not  in  our  Society)  who  would  sit  by  with  gomplacent 
smile  and  apparently  with  an  easy  conscience  as  they  adminis 
tered  flag-tea,  paregoric  or  so(jthing  syrup  and  waited  for  the 
tardy  action  of  a  small  dose  of  castor  oil  to  relieve  the  agony  of 
a  bottle  fed  baby  occasioned  by  the  ingestion  of  an  inordinate 
quantity  of  undiluted  cow's  milk,  filling  its  delicate  stomach  with 
undigested  casein  while  a  little  warm  water  introduced  by 
means  of  a  stomach  tube  would  remove  the  materies  morbi 
promptly  and  the  tranquil  infant  would  fall  asleep  in  the  moth- 
er's arms.  And  in  spite  of  this  the  self  constituted  doctor  swears 
at  the  thought  of  the  stomach  washing  and  condemns  the  ac- 
tion as  a  barbarous  practice. 

In  the  field.of  surgery  the  universal  concensus  of  opinion,  the 
dominating  thought,  the  paramount  central  idea  in  all  cases 
whether  minor  or  major,  is  perfect  cleanliness,  thorough  asepsis; 
and  their  results  are  so  convincing  as  to  exclude  the  idea  of 
doubt  as  to  the  correctness  of  their  method.  No  case  however 
trival  escapes  the  thoroughness  of  their  technique  and  it  is  com- 
forting to  observe  the  satisfactory  result,  alike  pleasing  to  patient 
and  doctor. 

I  observed  the  very  limited  use  of  iodoform  in  wound  treat- 
ment. Whether  this  was  due  to  the  superiority  of  other  antisep- 
tics or  was  simply  a  step  toward  economy  I  am  unable  to  say, 
but  the  results  were  satisfactory  to  the  patient  and  economical 
to  the  clincal  staff.  All  suppurating  wounds  were  treated  with 
moist  dressings  of  2  per  cent,  carbolic.  Any  physician  can 
equip  his  office  with  the  necessary  pharaphernalia  to  tieat  asep- 


■^QQ  MOOKE-POST-GRADUATE   INSTITUTION. 

tically  such  cases  as  would  be  likely  to  apply  for  office  treatment 
at  a  cost  not  exceeding  five  dollars,  and  his  results  would  pay  a 
handsome  in>^^erest  on  the  investment  and  a  comforting  solace  to 
his  owrs  conscience.  I  sometimes  think  if  we  would  do  less  work 
and  do  that  more  thoroughly,  we  would  better  maintain  our  own 
self  esteem  and  the  respect  of  our  clientele,  and  we  would  obviate 
the  necessity  of  encroaching  upon  our  brother  practitioners  sensi- 
bilities or  his  field  of  labor,  and  save  ourselves  the  tedium  and 
annoyance  of  free  practice  to  advance  agents  and  long  tougued 
grannies,  who  sing  our  praises  in  church  yards  and  chimney  cor- 
ners in  a  tune  and  to  a  meter  that  is  entirely  out  of  harmony  with 
the  occasion  or  the  subject.  'Tis  brains,  not  tongues,  thoughts, 
not  words  |„hat  encourage  our  confidence  and  inspire   our  faith. 

In  the  field  of  gynaecology  I  received  but  little  inspiration, 
except  perhaps  to  better  familiarize  myself  with  the  mode  of  ex 
amination  and  method  of  application,  and  confirming  my  opinion 
as  to  the  incurability  of  many  conditions  except  by  resort  to 
radical  operation.  So  far  nothing  has  superseded  the  tampons 
of  boroglyceride  as  a  local  application  to  the  pelvic  viscera,  or 
perhaps  the  addition  of  a  little  ichthyol  when  inflammatory  exu- 
dation was  well  marked.  In  simple  vaginitis  they  use  boric  acid 
on  absorbent  cotton  followed  by  astringent  douches.  The  phy- 
losophy  of  this  is  apparent  to  each  of  us. 

In  the  department  of  the  eye  and  ear  I  saw  nothing  worthy  of 
mention  because  at  the  same  hour  my  attention  was  directed  to 
the  nose  and  throat  with  the  special  view  of  observing  their 
treatment  of  catarrhal  conditions.  Here  we  had  an  abundance 
of  clinical  material,  and  to  me  some  very  interesting  conditions. 
In  private  practice  I  had  never  observed  a  deviated  septum,  but 
in  the  clinic  the  cases  were  frequently  seen  and  were  regarded 
as  a  patent  factor  in  producing  accute  rhinitis.  Adenoid 
growths  were  of  frequent  occurrence  and  occasional  much  diffi- 
culty in  breathing.  Their  treatment  is  removal.  These  cases 
bleed  very  freely  and  your  first  experience  will  doubtless  occa- 
sion you  some  alarm.  I  saw  the  operation  done  with  and  with- 
out an  anaesthetic  and  with  either  method  I  would  counsel  you 
have  none  of  the  family  present.  Tonsillitis  simple  and  follicu- 
lar was  treated  by  astringent  gargles  and  the  favorite-one  in  the 
clinic  was  equal  parts  of  alum,  borax  ;;nd  chlorate  potash — 5  i 


MOORE -POST-GRADUATE   INSTITUTION. 

to  ^  glass  water  as  gargle.  While  hypertrophied  tonsils  were 
removed.  Nasal,  postnasal  and  pharyngeal  catarrhs  were  treat- 
ed by  cleansing  douches  or  sprays,  the  removal  of  exciting  cause 
and  attention  to  general  health  by  appropriate  remedies.  This 
brings  me  to  the  miscellaneous  portion  of  my  paper  and  I  will 
give  such  notes  and  recipes  as  I  think  would  most  interest  you. 
The  chloride  of  ethyle  has  been  supplanted  by  a  more  efficient 
local  anaesthetic  in  what  is  known  as  Sleich's  mixture  which  is  a 
combination  of  hydrochlorate  of  cocaine  and  morphine  and  salt. 
It  can  be  had  in  hypodermic  tablet  form  fiom  any  of  the  manu- 
facturing chemists.  The  point  to  be  observed  in  the  useof  this 
remedy  is  to  inject  in  the  skin  at  several  points  and  not  subcu- 
taneously  and  we  do  morphia.  Sleich's  mixture  for  general 
anaesthesia,  while  warmly  advocated  by  some,  has  not  yet  been 
sufficiently  tested  to  gain  rank  over  Squibb's  ether  which  is  used 
in  the  greater  per  cent  of  cases. 

Antiseptic  irrigations  followingoperations  on  joints  and  abdo- 
men are  condemned  upon  the  theory  that  all  antiseptics  destro)' 
epithelium  instead  ol  protecting  it  and  the  treatment  sugges- 
ted is  y^-g-  of  \<fc  of  salt  in  sterile  water,  unless  in  tubercular 
disease  of  joint  peroxide  of  hydragen  or  bichloride  i  to  5,000  is 
used.  Stiff  joint  is  nearly  always  the  result  when  we  have  pus 
present.  Where  we  have  ulceration  on  the  scrotum  if  the  epidi- 
dymis alone  is  involved  it  is  tubercular,  and  if  the  testicle  alone 
it  is  syphilis. 

Treatment  for  epididymitis. 

Ten  per  cent,  solution    nitrate   silver,  and  if  that    don't  cure, 
put  to  bed,  apply  poultice  followed  by  icthyol  ointment. 
Treatment  for  orchitis. 

Iodide  Pot 3  i 

Tr.  Phytolacca    .      .      .      .     3  vi 

Aqua  q.  s 3  iii.      Sig    3  i  every  2  hours. 

Put  to  bed  and  apply  hot  flaxseed  poultice. 
Gonorrhoea  is  treated  by  injections  of  argonin  ^fo  solution,  and 
protargol  ^  to  ^  of  I'fo  solution  but  what  seemed  the  most 
popular  treatment  was  permanganate  of  potash  i  to  3,000  by 
irrigation  method.  No  medicines  internally,  unless  required  by 
complicatng  conditions. 
Local  treatment  for  Boils: 


302 


MOORE-POST-GRADUATE  INSTITUTIONS . 


Carbolic  Acid 


grs.  V.  to  X. 


Fl.  ext.  Ergot     .      ,      .     ,       3  i  to  3  ii 

Pulv  Amyli 3  ii 

Zinci  Oxidi 3  ii 

Rose  Water  Ung     ...       3  i 
Apply  every  12  hours. 
Local  treatment    for    Vv^arts  and  corns,  monochlor  acetic  acid 
or    terchloride    of   antimony.     Adlised    not    not  burn  a  wart  in 
patient  over  40;  in  such  cases  better  cut  it  out. 

Treatment  of  ganglion  is  injection  of  5  or  6  drops  Churchill's 
tr.  iodine,  pressure  made  after  2  or  3  days.  The  presence  of 
rice  bodies  in  ganglion  indicate  that  it  is  tubercular.  Hypertro- 
phied  scar  tissue  is  cured  by  injection  near  the  site  of  i^  watery 
solution  of  thiasinamine  3  times  a  week.  Bone  fellon  should  be 
cut  early  as  necrosis  of  bone  fellon  if  cut  after  the  8th  day. 

Rheumatism  in  the  acute  stage  is  treated  with  the  salicylates 
and  the  gubacute  or  chronic  by  the  addition  of  iodide  of  potash 
as  follows: 

5 — Solicylic  Acid 3  iii 

Bicarb  Soda 3  ii 

Iodide  Pot 3  iii 

Elix  Gaultheria §1 

Aqua  qs 3  iv 

M.— Sig— 3i  t.  i.  d. 

To  determine  synovitis  of  knee  joint  place  hand  above  the  knee 
and  press  down  and  if  the  joint  is  normal  the  patella  will  lie  flat, 
if  synovitis  it  will  be  elevated  and  there  will  be  puffiness.  In 
the  first  stage  patient  feels  like  he  has  a  cushion  in  the  knee. 
Treat  by  placing  a  posterior  splint  and  bandage  from  toe  to  knee, 
skip  the  knee  and  go  above  and  bandage  then  go  back  to  knee 
and  bandage,  by  this  means  the  knee  can  be  dressed  without 
disturbing  the  splint.  I  never  use  a  blister  on  the  knee,  but 
simple  counter  irritants  as  the  tr.  iodine.  In  hip  joint  disease  in 
ist  stage  use  traction  and  fixation;  in  the  2nd  stage  the  same; 
and  in  the  3rd  stage  fixation  only.  The  early  signs  of  phthisis 
are  difficulty  in  movement  of  the  chest  walls  or  lack  of  motion, 
high  pitched  respiratory  murmur,  dullness  on  percussion  and 
bronchial  breathing.    In  acute  phthisis  give 


MOORE-POSTGRADUATE  INSTITUTION. 

Beechwood  Creosote 

Tr.  Gent.  Co.  aa.        .      .  3  ii 

Whiskey  qs 3  viij 

Sig.   Teaspoonful  in  wineglass  water  or  milk   an   hour  after 
meals,  increased  50^  every  10  days  till  tablespoonful  is  reached. 
For  emphysema,  give 

Liq  Ammon  Annis     .     .  §  ss 


Aqua 


VI 


Iodide  Pot 3  ii 

Simple  Syrup  ....  |  ii 
Sig.  }4  to  I  tablespoonful  every  2  to  4  hours. 
For  asthma,  pyridine  15  drops  by  inhalation  will  give  relief 
in  15  minutes  but  the  objection  is  its  stench;  next  best  is  iodide 
of  ethyl  15  to  20  drops  by  inhalation  which  will  relieve  it  in  30 
minutes.  As  an  internal  remedy  they  use  fl.  ext.  quebracho  in 
hofwater. 

The  cough  remedies  used  as  expectoratus  were  apomorphine 
and  cocillana.      Erysipelas  by  some  was  treated  with  10^  ichthyol 
and    by   others   with    pure    carbolic  acid   as  mentioned    in  our 
previous  meeting.      Chlorosis  or  green  sickness  generally  comes 
on  ab(.ut  the  third  year  after  beginning  of  menses,    which  may 
be  normal,  excessive  or  absent.      Takes  about  six  weeks  to  cure 
these  cases.     Give  them  good  food,  fresh  air  and  exercise. 
T^ — Tr.  Nux  Vom.      .      .      .     3  ss 
Dil.  Mur.  Acid   .     .      .       3  ii 
Tr.  Gent.   Co.      .      .      .       |  i 

Aqua  qs 3  iij 

Sig.  Teaspoonful  ihree  times  a  day  before  meals,  also  give  a 
teaspoonful  of  the  following  after  meals.  (Always  keep  the 
bowels  open  with  aloes.) 

5— Tr.  Ferri  Chlor. 
Glycerine 

Aqua  aa     .     .     .      f  i 
Sig.— 3i  t.i.d. 

Should  the  iron  disagree  give  Blaud's  pills  or  Gudes  Pepta- 
mangan.  Chorea  was  treated  with  ascending  doses  of  arsenic 
to  point  of  tolerance.  Neuritis  with  strychnia  in  same  manner. 
In  digestive  disorders  always  regulate  the  diet,  yi  of  food   stuff 


.Q.  MOORE— POST-GRADUATE  INSTITUTION. 

peptonized  in  the  stomach  and  ^  in  the  intestinal  canal.     If  the 
stomach  is  faulty  give  hydrochloric   acid    and    if   the  intestinal 
digestion  is  faulty  improve  the  oxidizing  condition  of  the  system 
by  giving  pure  creoline  and  ox  bile,    with    the  addition   of  colo- 
cynth  or  podophyllin  if  constipation  is  present. 
For  acid  eructations  of  flatulency. 
Bicarb  Soda 
Magnesia. 

Sabgallate  Bismuth  aa  grv.     Before  meals. 
For  nervous   dyspepsia,    give  pepsin  5  gr.,  brom  pot.   10  gr., 
and  charcoal  10  grs.  in  camphor  water  after  meals. 

For  dilatation  of  stomach  give  resorcin  3  gr.  bismuth  20  gr. 
one  half  hour  before  meals.  In  all  cases  of  eczema  examine  the 
scalp  as  seborrhoeic  eczema  represents  8ofi  of  all  eczema  and 
causes  92^  of  all  cases  of  alopecia.  Shave  the  head  and  apply 
sulphur  ^  i  to  |  i  oint.  or  5^  to  10^^  resorcin  in  alcohol,  apply 
every  night  and  use  no  ammonia,  as  the  hair  will  come  out. 
Erythematous  exzema.      Promote  diuresis  and  use  as  lotion. 

Salicylate  soda grs.  xxv 

Carb.  Magnesia        ....     grs.  xv 

Ox.  Zinc grs.  xv 

Rose  Water 3  i 

Parasitic  eczema,  ichthyol  lofc  to  3  i  Zinc  Aug,  or  salicylic  acid 
5^  Bal.  Peru  10^  to   3  i  Zinc  ung. 

Impetigo — Stop  all  soaps  and  useonlj'  emollient  salves. 
Psoriasis — Give  arsenic  internally  to  point  of  tolerance  and 
Pyrogallic  Acid     ....      5^ 
Oil  Ricini 

Alcohol aa   3  i 

Ringworm  of  the  body  use  white  prec  ointment.     In  ringworm 
of  scalp. 

Pyrogallic  Acid 
Schthyol     .     .     .      .     aa  5 
Salicylic  Acid      ...      2 
Vaseline  and  Lonoline  equal  parts 
Also  sometimes  used  2  to  5  gr.    bichlor.  mercury   to   3  i  kero- 
sene oil.     A  difficult  condition  to  cure,  lasts  from  six  to  twelve 
months. 


CORRESPONDENCE.  -q- 

Alopecia,  carbolic  acid,  tr.  iodine  and  chloral  hydrate,  equal 
parts. 

The  notes  and  receipts  which  I  have  read  are  such  as  I  picked 
up  from  the  different  departments  and  are  presented  for  your 
consideration  rather  than  your  acceptance  or  endersement,  for 
many  of  them  are  new  to  me  and  I  shall  select  my  cases  and 
judge  of  their  usefulness  when  I  have  given  them  practical  test. 

In  summing  up  my  opinion  on  post  graduate  study,  I  must 
differ  from  that  of  some  doctors  who  for  some  reason  see  it  in  a 
different  light  from  myself  and  with  cordiality  of  spirit  I  give  it 
my  hearty  endorsement. 

It  is  a  refreshing  educational  shower  that  stimulates  new 
germs  of  thought  and  inspires  the  old  with  renewed  vigor  and 
life,  it  expands  and  broadens  because  we  see  and  know  more 
clearly ;  it  invigorates  and  stimulates  because  it  brushes  away 
some  of  the  dusty  cobwebs  and  mirrors  some  of  the  advanced 
thought  in  medical  science.  It  pays,  not  only  the  head  but  the 
pocket  as  well. 


(Iorrc6pon^cnce. 


THE  PRESENT  SITUATION. 


Editor  N.  C.  Medical  Journal: 

In  the  editorial  of  the  last  number  of  your  esteemed  Journal 
I  noticed  an  article  which  seemed  to  me  to  be  peculiarly  appro- 
priate to  the  present  time,  in  bringing  before  the  profession  the 
more  material — aside  from  the  ethical — part  of  the  daily  life, 
and  pointing  out  the  total  lack  of  business  sagacity  extant,  and 
the  improvident  thoughtlessness  of  futurity,  financially  speaking, 
among  us. 

Among  one  of  the  first  lessons  inculcated  upon  the  physician's 
mind  is  that  the  practice  of  medicine  is  somehow  conducted  on 
a  wrong  and  unsubstantial  basis,  and  that  gratitude  is  an  x 
quantity  among  patients. 

Somewhat  later  he  learns  that  the  world  is  conducted  on  a 
business  basis,  pure  and  simple;  and   that   flights  of   the   ideal. 


3o6  CORRESPONDENCE. 

and  pla3^s  of  sentiment,  are  strangely  out  of  place  in  this  the 
dawn  of  the  twentieth  century. 

He  feels  that  the  code  written  to  guide  physicians  in  their 
conduct  in  the  remote  and  chivalric  past,  is  too  Utopian  for  the 
assertive  present,  and  that  it  needs  revision  sadly,  especially  re- 
garding its  financial  portion. 

Still  later  he  sees  the  utility  of  having  strict  business  rules, 
and  abiding  by  them.  In  other  words,  he  sees  the  world  is  op- 
posite of  sentimental;  that  it  expects  him  to  follow  his  business 
in  a  business  way,  and  that  if  he  does  not  do  so  and  makes  a 
financial  failure,  he  only  is  to  blame.      Quite  logical  loo,  isn't  it? 

In  these  modern  days  the  physician  is  not  looked  upon  as  such 
a  paragon,  but  is  valued  solely  for  his  skill  and  knowledge  of 
medicine. 

His  anxiety,  worry,  sleepless  nights,  and  sympathy  have  no 
market  value;  they  are  entirely  excraneous  to  the  purpose  in 
view.  He  is  supposed — nay,  is  cotnmanded  to  exercise  a  given 
degree  or  amount  of  skill,  for  its  equivalent  in  gold.  Higher 
consideration  of  gratitude  etc.,  for  the  invaluable  work  done 
are  utterly  ignored :  the  case  well,  and  the  doctor  paid — that 
ends  the  matter!  They  feel  under  no  obligation  whatever  to 
the  physician  and  have  not  the  least  compunction  of  feeling  in 
discarding  him  and  calling  in  another  doctor  in  the  very  next 
case. 

The  world  forces  us  to  look  upon  the  matter  as  a  business 
transaction,  and  forces  us  to  receive  it  as  such — whether  we 
will  or  not. 

Other  valuable  lessons  he  learns  (or  should),  in  the  battle  of 
life;  and  while  comparisons  are  odious,  still  he  is  often  found 
comparing  his  profession  with  others  in  the  matters  ot  work, 
leisure,  remuneration,  health,  pleasure,  wealth  etc.,  and  usually 
with  detriment  to  his  own. 

A  great  many  physicians  have  a  false  conception  of  the  prac- 
tice of  medicine ;  they  set  themselves  up  as  demigods,  to  deal 
out  life  and  death,  to  give  complete  immunity  from  past  errors, 
and  sins  committed  etc., — and  expect  to  be  regarded  as  having 
that  prerogative.  Their  lives  are  visionary,  with  no  thought  of 
the  morrow,  or  of  health,  or  finances — their  self-aggrandize- 
ment is  reward  enough!     They  are  "working   for   the  good  of 


CORRESPONDENCE.  .^ 

humanity,"  they  say — yet  if  you    will    follow   their  death  lists, 
the  contrary  seems  more  true! 

"Working  for  the  good  of  humanity"! — when  they  should 
have  sense  and  foresight  enough  to  work  for  their  own  families 
— to  provide  for  themselves,  their  wives  and  children  against 
the  days  of  need  and  old  age;  for  the  old  adage  says  tbat  "he 
who  does  not  provide  for  his  own  family  is  worse  than  an  infi- 
del." Moreover,  brother,  who  would  take  it  upon  himself  to 
provide  for  your  family  in  case  of  your  demise — would  any  of 
your  favored  patients,  or  friends? 

Just  such  men  are  the  ones  who  are  ruining  the  prolession 
to  day  with  their  lax  business  methods — their  supposed  mag- 
nanimity and  charity(?).  They  practice  indiscriminately  among 
loafers,  and  dead-beats — in  fact  anybody  who  will  send  for 
them,  simply  for  appearances  and  to  say  they  are  "busy," 
thereby  encouraging  thriftlessness,  idleness  and  dishonesty. 
They  keep  men,  by  so  doing,  from  paying  some  honest  doctor 
his  dues,  and  create  a  large  contingent  of  worthless  practice  in 
every  community.  People  have  sense  enough  to  know  that  a 
doctor  cannot  spend  years  of  study,  and  thousands  of  dollars 
for  education,  books,  instruments  etc.,  pay  his  expenses  (for, 
bless  you  they  expect  the  doctor  to  pay)  and  work  for  nothing! 
Do  they  expect  it  of  a  lawyer?  Do  they  expect  a  merchant  to 
give  his  wares  away?  Do  they  expect  the  minister  to  endeavor 
to  save  souls  gratis?     No! 

Is  the  doctor  then  better  than  all  these? — or  is  he  a  bigger 
fool?  Whose  fault  is  it  that  the  present  state  of  affairs  exists? 
Does  it  take  occult  science  to  determine? 

We  have  excellent  medical  laws  in  this  State,  perhaps  the  best 
in  the  union  regarding  the  practice  oi  medicine,  but  what  laws 
have  we  for  the  collection  of  our  bills,  after  the  practice?  We 
are  not  as  well  off  there  as  the  common  laborer  In  all  States, 
and  most  counties  and  cities,  hospitals,  asylums,  homes  and 
dispensaries  are  provided  for  the  worthy  indigent,  and  their 
officers  are  paid  salaries  by  the  city,  county,  or  State.  Yet  there 
are  some  physicians  in  this  (and  I  presume  in  every  State)  who 
apparently  think  this  work  comes  under  their  jurisdiction,  and 
attempt  to  do  it,  when  the  State  does  not  ask  it,  and  is  fully 
able  and  capable  of  caring  for  her  poor. 


,o8  CORRESPONDENCE. 

However  to  the  worthy  poor  no  one  will  deny  service,  but  im- 
position is  practised  in  90^  of  all  cases  regarded  and  treated  as 
such,  and  it  is  just  that  90^  that  need  looking  after  with  the 
closest  scrutiny. 

The  time  is  present  for  the  practice  of  medicine  to  be  placed 
on  a  sensible,  business  basis,  and  to  relegate  to  hopeless  oblivion 
the  chimeras  of  the  past. 

Let  the  people  know  that  you  intend  to  be  paid  for  your 
work, — tell  them  how  much  better  service  you  will  be  able  to 
give  them  from  hospital,  laboratory,  and  other  advantages 
secured  from  the  proceeds;  and  that  you  much  prefer  idleness 
to  wearing  yourself  out  working  for  nothing  and  fostering  lazi- 
ness and  dishonesty.  If  they  cannot  pay  all,  make  them  pay  pro- 
portionately. They  will  respect  you  more,  have  moie  faith  in 
your  skill,  and  will  soon  co-operate  with  you  for  mutual  benefit. 

The  fees  for  some  things  are  rather  too  high,  I  think,  to  be 
conductive  to  honesty  in  payment.  Perhaps  a  little  reduction 
would  have  a  wholesc»me  influence  in  that  particular. 

Finally,  from  all  directions  comes  the  tidings  that  the  medical 
world  is  awakening  from  its  long  lethargy,  and  that  the  practice 
of  medicine  is  destined,  ere  long,  to  be  placed  on  scientific, 
reasonable,  and  sensible  lines. 

It  behooves  us  all,  therefore,  to  hasten  the  day. 

J.  Thomas  Wright,  M.  D. 


The  New  York  Evening  Post  of  March  26,  in  a  semi-editorial 
article,  shows  the  following  remarkable  appreciation  of  the  work 
and  character  of  physicians:  "Their  opportunity  is  unique,  but 
their  influence  and  assistance  in  the  history  of  our  households  is 
a  great  testimony  to  the  sympathy  and  patience  and  large- 
hearted  comprehension  of  man  with  and  for  his  fellow  man  in 
this  urgent,  crowded,  self-seeking  age  of  ours.  Human  brother- 
hood, which  has  no  name  or  guild,  is  vitally  alive  among  our 
doctors.  Sleepless  nights  and  anxious  d  lys,  hours  of  tense  ap- 
prehension, the  exertion  of  almost  superhuman  ingenuity  to 
relieve  pain,  mark  the  going  to  and  fro  of  many  a  quick-moving 
'buggy'  in  our  streets;  and  if  one  in  a  thousand  is  so  fortunate 
as  to  acquire  wealth  as  the  result  of  his  practice,  let  us  rejoice 
for  him. " — Medical  Ase. 


NORTH  CAROLIN/\  MEDICAL  JOURNAL, 

ROBERT  D.   JEWETT,  M.D.,  Editor 


DEPARTMENT  EDITORS 

(      H.  T.  Bahnson,  M.D.,  Salem,  N.C. 
SURGERY:     -      R.  L.  Gibbon. M.D.,  Charlotte.  N.  C. 

f      J.  Howell  W  ay,  M.D.,  Waynesville,  N.  C. 

NERVOUS  DISEASES:— J    llison  Hodges,  M.D.,  Rcihmond,  Va. 

PRACTICE  OP  MEDICINE.  ]    S-  ^'j^J^Jii?^^™'.  ^^•°-'  ^^  «•  N- 

<»^cT^^^^T>Tr'a.      J      GEORGE  G.  THOMAS,  M.D.,  Wilmington,  N.  C. 
OhJSii.llviCb.      ^      ^   L.  Payne,  M.D,,  Norfolk,  Va. 

(      H.  S.  LOTT,  M.D..  Winston,  N.  C. 
GYN.'ECOLOGY:      \      J.   W.  Long,  M.D.,  Salisbury,  N.  C. 
(      H.  A.  ROYSTER,  M.D.,  Ralei;^h,  N.  C. 

PATHOLOGY:— Albert  Anderson,  M.D.,  Wilson,  N.  C. 
PEDIATRICS:— J.  W.  P.  Smithwick,  M.D.,  La  Grang-e.  N.  C. 
TRANSLATION  AND  FOREIGN  REVIEWS: 
Richard  H.  Whitehead,  M.  D.,  Chapel  Hill,  N.  C. 


All  communications,  either  of  a  literary  or  business  nature,  should  be 
addressed  to,  and  any  remittances  by  P.  O.  Order,  Draft  or  Registered  Let- 
ter, made  payable  to  Robert  D.  Jewett,    M.D.,  Winston,  N.  C. 


EMtodaL 


TIMELY  SUGGESTIONS. 


The  address  of  Dr.  Francis  Duffy,  President  of  the  State 
Medical  Society,  which  was  delivered  before  the  Society  a  few 
days  since,  appears  in  this  issue  and  is  well  worthy  of  consid- 
eration, not  only  by  the  Society  as  a  body  but  by  the  individual 
members.  The  matter  of  the  earlier  meeting  of  the  Bo  ,rd  of 
Examiners  has  been  agitated  several  times  at  Society  meetings, 
and  we  are  pleased  to  note  that  the  suggestion  was  acted  upon 
this  year  by  the  Board.  The  membership  of  the  Society  has 
been  rather  on  the  decrease  the  past  few  years,  and  this  is  due, 
in  a  very   great    measure,    to   the   fact   that  the  applicants   for 


license  have  been  unable  to  join  at  the  time  of  their  examina- 
tion. We  agree  with  the  President  in  believing  that  it  would 
be  wise  to  remit  the  initiation  in  the  case  of  new  licentiates  who 
desire  to  unite  themselves  with  the  Society.  They  have  been 
at  considerable  expense,  and  most  of  them  must  regard  seriously 
the  expenditure  of  each  dollar.  There  can  be  no  doubt  that 
quite  a  number,  who  would  make  good  members,  drift  off  and 
never  attend  a  meeting,  and  feel  that  they  are  getting  along 
quite  as  well  without  being  affiliated  with  the  Society.  This  is 
not  so,  however.  The  Society  needs  all  the  members  possible, 
for  each  one  adds  his  influence,  be  it  greater  or  less,  to  the  ac- 
complishment of  those  objects  for  which  the  Society  is  striving, 
and  these  objects  attained,  redowned  to  the  benefit  of  all  the 
profession. 

The  modern  tendency  on  the  part  of  the  profession  to  follow 
all  the  therapeutic  and  surgical  fads  that  are  daily  arising,  is  to 
be  greatly  depreciated.  There  seems  to  be  a  feeling  on  the 
part  of  Dr.  A.  that  he  will  not  be  considered  up-to-date  if  he 
allows  Dr.  B.  to  get  ahead  of  him  in  the  use  of  some  new  thing 
or  idea.  It  would  be  well  to  permit  these  new  things  to  season 
awhile  before  adopting  them  in  your  practice.  They  frequently 
emanate  from  the  brain  of  some  man  who  is  seeki-ig  fortune  or 
fame,  and  a  little  experience  would  probably  make  one  content 
to  let  them  religiously  alone.  There  may  be  such  a  thing  as 
too  much  medication,  anv  way.  We  should  not  lose  sight  of 
the  tact  that  Nature  is  the  power  which  cures  the  patient — it  is 
the  physician's  part  to  assist  her.  The  mighty  ship,  with  its 
human  freight,  needs  the  pilot  to  guide  her  upon  the  trackless 
ocean  lest  she  go  astiay,  but  it  is  the  ship  and  not  the  pilot  that 
bears  the  freight  to  its  destination.  In  disease  (generally)  it  is 
the  physician's  part  to  aid  Nature  in  keeping  in  the  way  that 
leads  to  recovery,  but  it  is  Nature  that  causes  the  recovery. 
We  had  better  learn  to  say  "the  patient  recovered,"  not  "we 
cured  him." 


When  writing  to  advertisers  please  mention  this  Journal. 


^ranelatione  anb  jforcion  IRcviewe. 

IN    CHARGE   OF 

Richard  H.  Whitehead,   M.D.,   Chapel  Hii.l,   N.   C. 


Persistent  Vitelline  (Omphalo-Mesenteric)  Duct  and  its 
Consequences.— In  the  Deutsch.  Med.  Woch.  No.  7,  1898,  W.  Korte 
gives  an  account  of  this  condition,  and  narrates  a  case  submitted  to 
oiDeration.  As  is  well-knowu  the  vitelline  duct,  which  during  early 
foetal  life,  connects  the  yolk-sack  with  the  small  intestine,  usually 
atrophies  and  disappears  so  that  at  birth  only  very  slight  remains  can 
be  detected  in  the  navel  and  umbilical  cord.  Should,  however,  the 
duct  fail  to  atrophy,  malformations  result  which  are  liable  to  be  at- 
tended by  serioi;s  consequences.  These  may  take  one  of  these  grades.  ' 
In  the  first  and  most  frequent  case  the  origin  of  the  duct  from  the 
ileum  remains  open,  and  constitutes  the  so-called  diverticulum  of 
Meckel.  This  presents  itself  as  a  blind  pouch  growing  out  from  the 
ileum  at  a  point  which  varies  from  15  to  20  inches  above  the  ileo-coeeal 
valve  and  is  composed  of  all  three  coats  of  the  gut,  serous,  muscular, 
and  mucous.  There  is  no  means  of  detecting  it  in  the  unopened  abdo- 
men. This  diverticulum  may  give  rise  to  dangerous  sickness  in  sev- 
eral ways.  Foreign  bodies  may  be  impacted  therein  and  lead  to  per- 
foration.    Korte  has  seen  such  a  case  due  to  cherry  stones. 

Again,  by  contracting  adhesions  with  the  abdominal  wall  or  sur- 
rounding organs,  the  diverticulum  forms  a  sling  under  which  a  loop 
of  intestine  may  become  strangulated.  Sometimes  a  fibrous  cord  runs 
from  the  apex  of  the  diverticulum  to  the  navel,  representing  the 
omphalo-mesenteric  vessels,  and  this  is  very  apt  to  cause  intestinal 
obstruction.     Korte  has  seen  four  such  cases. 

In  the  second  grade,  remains  of  the  living  mucous  membrane  of  the 
duct  are  left  in  the  navel  which  develop  tumors— the  so-called  umbili- 
cal teratomata.  While  in  these  cases  there  is  no  communication  be- 
tween the  navel  and  the  intestine,  a  fibrous  band  sometimes  connects 
the  two,  indicating  the  site  ot  the  original  duct. 

In  the  third  grade,  the  entire  duct  persists  as  a  canal  composed  of 
all  the  coats  of  the  intestine  running  from  the  navel  through  the  ab- 
dominal cavity  into  the  ileum.  This  condition  is  usually  discovered 
soon  after  birth.  When  the  cord  drops  off  a  small  red.  moist  swelling, 
which  is  generally  taken  to  be  a  clump  of  granulations,  is  noticed  i!\ 
the  navel.  Soon,  however,  it  is  observed  that  foecal  matter  sometimes 
escapes  at  this  point,  and  then,  introducing  a  probe,  the  physician  re- 
cognizes the  presence  of  a  fistulous  passage  into  the  intestine.  With 
this  condition  there  ai-e  connected  dangers  of  a  peculiar  sort,  the  prin- 
cipal one  of  which  is  prolapse  of  intestine.  During  crying  and  other 
muscular  efforts  of  the  infant,  the  duct  is  imaginated  and  everted,  so 


-  J  2  CURRENT  LITERATURE. 

that  a  long,  sausage-like  body  covered  with  mucous  membrane  projects 
out  of  the  navel,  to  be  usually  rdeuced  when  the  abdomen  becomes  lax. 
The  prolapse  does  not  consist  only  of  the  mucous  lining  of  the  duct, 
as  has  been  supposed,  but  all  of  its  coats  takepart  in  the  imagination. 
Should  then,  the  surgeon  cut  away  the  prolapse  of  its  base  he  would 
open  into  the  abdominal  cavity.  As  time  goes  on,  the  prolapse  is  in- 
creased, and  the  duct,  which  we  have  seen  is  directly  continuous  with 
the  ileum,  drags  that  intestine  along  after  it,  and  finally  acute  intesti- 
nal obstruction  is  produced.  When  this  stage  has  been  reached  all 
cases,  so  far  as  is  now  known,  end  fatally.  Operation  under  such  cir- 
cumstances is  exceedingly  difficult  and  dangerous,  however,  such  chil- 
dren are  from  the  beginning  badly  developed,  and  suffer  from  intesti- 
nal catarrh,  and   consequently  are  jioor  subjects  for  operation. 

Thei-e  are  two  other  ways  in  which  the  persisting  vitelline  duct  may 
lead  to  obstructing  the  bowels.  In  the  first  case  a  knuckle  of  bowel  is 
pushed  into  the  space  between  the  prolapsed  duct  and  the  circumfer- 
erence  of  the  navel  and  there  strangulated;  while  in  the  second  the 
duct  running  through  the  abdominal  cavity  acts  as  a  cause  of  stran- 
gulation in  the  manner  previously  mentioned. 

In  the  way  of  treatment,  cauterization,  ligature,  and  excision  have 
all  failed.  Even  if  the  mouth  of  the  duct  be  closed  by  caustics,  the 
main  body  of  the  duct  remains  open,  and  prolapse  will  recur  through 
the  sear — on  the  other  hand  if  we  successfully  remove  the  prolapse  by 
ligature  or  excision — very  dangerous  to  themselves  owing  to  the  lia- 
bility to  opening  of  the  abdomen  or  inclusion  of  the  ileum — the  intes- 
tine is  left  adherant  to  the  back  of  the  navel,  and  the  danger  of  stran- 
gulation is  as  great  as  before. 

In  view  of  the  great  danger  of  this  condition  and  the  failure  of  other 
treatment,  Barth  suggested  excision  of  the  entire  abnoi'mal  structure 
including  its  openings  on  the  navel  and  into  the  ileum.  Korte  reports 
at  length  a  case  successfully  operated  upon  by  himself,  and  mentions 
seven  cases  treated  in  the  same  way  by  other  surgeons,  five  of  which 
were  cured,  two  dying. 


IRcview  of  Current  Xitcrature. 


PEDIATRICS. 

IN   CHARGE  OF 

W.  P.  Smithwick,  M.  D.,  LaGrange,  N.  C. 


A  New  Diagnostic  Sign  of  Me  a  sees  :-Dr.  Henry  Koplik,  (  Medical 
Record,  Vol.  58,  no  05),  describes  a  new  sign,  which  he  claims,  is 
absolutely  pathognomonic  of  the  disease.    It  consists  of  minute  bluish- 


CURKKNT  LITESATURE. 

white  specks,  punctate  in  charaoter,  situated  in  the  centre  of  the  reddish 
areas  which  cover  the   mucous  membrane  of  the  cheelcs  and  lips  in  the 
beginning    of    the  disease.      As    the   exanthem  appears    and    spreads 
on   the  skin,   the  eruption  on   the   mucous  membrane  of  the  lips   and 
cheeks  becomes  diffuse,  losing  the  characters  of    a  discreet  eruption, 
and  we  have  an  intense    general  redness  which  is  simply  dusted  over  by 
myriads  of  these  bluish-white  specks.     When  theexanthem  is  at  its  heigt 
the  buccal  eruption  begins  to  fade,  and  in  the  latter  stages  of  the  fading 
of  the  skin  eruption  the  phenomena,  described  above,  entirely  disappear. 
In  order  to  recognize  and  properly  appreciate  the  above  sign  the  patient 
must  be  examined  in  the  strongest  day  light,  and  the  mucous  membrane 
of  the  cheek  everted  so  as  to  expose  it  thoroughly  to  the  light.     Then 
we  see  a  minute  bluish-white  spot  situated  in  the  centre  of  the  irregular 
reddish    spots    which   cover    the    mucous    membrane    of     the    cheeks 
and  lips,  and  doe  not  occur  elsewhere.  He  says  they  cannot  be  mistaken 
for  .'iprue,  as  they  are  not  so  deeply  white,  nor  are  they  as  large,  nor  do 
they  coalesce  to  become  plaque-like  in    form,    and  they  always    retain 
jjunctate  form.     The  value  of  this    sign   seems  to  lie  in  the  fact  that  an 
early  diagnosis  of  measles  can  be  absolutely  made,  and  isolation  per- 
fected before   exposure  is  great,  and  it  ought  to  be  sought    for  by  all 
phy8icia,ns  when  they  are  called  to  cases  that  do  not  admit  of  an  easy 
diagnosis.  j.  \v.  P.   S. 

A  Contribution  to  the  Therapeutics  of  Enuresis:— An  acci- 
dental discovery  was  made  in  the  treatment  of  this  ti-ouble  by  Dr. 
Alfred  Hand,  Jr.,  (Pediartics,  Vol.  5,  No  7),  He  prescribed  pills  of 
following  composition: 

Ext.  Cannab.  Ind gr.  1-8 

Hyoscyam gr.  1-100 

Zinc.  Phosphid.     .     , gr.  1-10 

for  the  mother  who  was  suffering  from  nervousness  incident  to  the  car« 
of  the  child.  She  misunderstood  the  directions  and  gave  them  to  her 
child  with  the  result  that  the  enuresis  ceased  in  two  days,  and  had 
not  returned  at  the  end  of  six  weeks,  the  time  of  the  writing. 

.1.  W.  P.  S. 


GENERAL  SURGERY. 

IN  CHARCJE  OF 

H.  T.  Bahnson.  M.D.,  R.  L.  Gibbon,  M.D. 

J.  Howell  Way,  M.D. 


Treatment  of  inguinal  Hernia  By  Injection.— Dr.  Theo, 
Griffin  (Int.  .Jour.  Surg.)claims  to  have  produced  some  very  successful 
cures  in  the  treatment  of  inguinal  hernia  by  injection.     The    following 


314 


CrRREXT   LITEKATIRE. 


is  his  method  in  detail: — I  prepare  my  patient  by  first  seeing  that  he 
has  a  truss  that  retains  the  gut  perfectly.  It  must  not  be  allowed  to 
rest  within  the  inguinal  canal,  but  must  be  held  out  of  it  by  the  pad  of 
a  truss  that  fits  firmly  over  the  internal  abdominal  ring.  Having  acer- 
tained  that  this  is  well  done,  aftei-  two  or  three  days'  observation,  we 
are  now  ready  to  proceed  with  the  injection.  I  desire  to  state  here  that, 
in  a  majority  of  cases,  during  the  treatment  the  patient  can  remove  the 
truss  at  night,  taking  it  off  and  putting  it  on  while  in  a  reclining  posture, 
buc  under  no  circumstances  must  the  gut  be  alowed  to  come  down. 

The  patient  now  lies  down  upon  the  table,  and  we  scrub  the  parts 
thoroughly  with  warm  water  and  soap,  dry  well,  and  finally  bathe  with 
a  2  per.  cent  solution  of  bichloride  of  mercury,  cutting  the  hair  shoi^t 
over  the  seat  of  the  proposed  puncture.  I  now  inject  hypodermically 
a  5  per.  cent  solution  eucaine,  about  one-half  to  the  inside  and  a  little 
below  the  external  abdominal  ring.  Wait  now  two  or  three  minutes 
for  the  local  action  of  the  anesthetic,  during  which  time  a  syringe  is 
charged  with  10  to  15  minims  of  the  injection  fluid  mentioned  in  my 
previous  article,  or  the  following  which  I  sometimes  use. 
3 — Fid.  ext.  quercu  alb.  .  .  .  3  iv. 
Tinct.  caniharides     ....      3  1. 

Acid  carbolic m  x. 

IM.  Sig. — Inject  10  to  15  minims  as  directed. — This  syringe  is  furni  she  d 
with  a  silver  probe,  known  as  a  cocaine  applicator,  which  can  be  ob- 
tained of  any  instrument  seller,  and  can  be  screwed  on  the  syringe  in 
the  place  of  the  hypodermic  needle.  Have  this  in  readiness  for  the 
purpose  of  placing  the  fluid  into  and  along  the  inguinal  canal.  I 
now  take  a  small  trocar  and  canula — I  use  one  which  I  found  in  a  vetei-- 
inary  hypodermic  case — and  plunge  it  into  the  tissue  at  the  i)oint  where 
the  local  anesthetic  was  injected;  direct  the  point  of  the  trocar  towards 
the  external  abdominal  ring,  pushing  it  up  to  the  ring  if  possible. 
NOW  withdraw  the  trocar  and  invaginate  the  index  finger  in  the  loose 
folds  of  the  scrotum,  and  push  it  up  to  and  into  the  external  abdominal 
ring.  As  the  finger  reaches  the  ring  it  will  come  in  contact  with  the 
canula,  which  has  been  left  in  the  tissues.  With  the  free  hand  guide 
the  point  of  the  canula  into  the  ring,  aided  by  the  iuvaginatei  finger. 
As  soon  as  the  point  of  the  canula  is  engaged  in  the  ring,  depress  the 
free  extremity,  bringing  the  canula  almost  parallel  with  Poupart's 
ligament,  and  force  the  canula  gently  into  inguinal  canal.  It  should 
be  passed  the  full  length  of  the  canal,  if  possible.  This  being  done 
I  take  up  the  syringe  with  the  silver  probe  attachment,  containing  the 
injection  fluid,  and  pass  the  probe  point  through  the  canula  to  the 
internal  abdominal  ring.  The  point  should  project  a  little  beyond  the 
end  of  the  canula,  so  that  none  of  the  injected  fluid  will  run  back 
through  the  canula.  Having  done  this,  slowly  inject  the  fluid,  at  the 
same  time  kneading  the  tissue  over  the  canal  with  the  fingers,  gradually 
withdrawing  the  canula  and  syringe  point. 

In  this  manner  we  surely  get  the  fluid  where  we   want  it.     It  is,  how- 


NOTES    AND   ITEMS. 


315 


ever,  sometimes  difficult  for  me  to  get  into  the  inguinal  canal,  but 
perseverance  usually  results  in  success.  The  external  ring  is  rendered 
more  open  and  is  more  accessible  by  having  the  leg  Hexed  upon  the 
thigh.  There  is  usually  some  swelling,  but  little  pain  or  inconveni- 
ence results;  so  far  I  have  had  no  abscess  or  suppuration  of  any  kind. 
I  have  been  recently  informed  that  two  of  the  cases  reported  by  me  have 
relapsed — case  ISio.4  with  an  omental  hernia,  and  case  No.  5  which  a*- 
the  time  of  my  report  I  had  just  discharged  from  my  ti'eatment 
Since  then  I  have  treated  two  other  cases,  the  ultimate  result  of  which 
it  is  to  early  too  ascertain.  The  chief  difficulty  in  the  way  of  successful 
treatment  is  to  get  the  injection  jiroperly  into  the  inguinal  canal.  If 
this  is  well  done  the  chances  are  good  for  a  cure.  The  unsuccessful 
results  are,  no,  doubt,  in  a  marjority  of  cases  due  to  the  failure  of  the 
operator  to  do  his  work  properly.  Each  patient  should  have  at  least 
three  or  four  injections;  this  is  an  arbitrary  rule,  as  there  is  nothing 
to  guide  you  as  to  the  exact  number  required. 


motc6  anb  Uteme, 

Dk.  Roscoe  E.  Franklin,  of  Richmond,  Virginia,  has  gone 
to  seek  his  fortune  in  the  Klondike  gold  fields. 

Dr.  W.  Clair  Spruell  has  been  reappointed  resident  physician 
at  the  University  Hospital,  Baltimore.  A  very  richly  deserved 
compliment. 

Board  of  Examiners. — There  were  upwards  of  eighty  appli- 
cants before  the  Board  at  the  Charlotte  meeting,  just  closed. 
At  time  of  going  to  press  the  number  of  successful  applicants 
had  not  been  determined  upon. 

The  Medical  College  of  Virginia  graduated  39  Doctors  of 
Medicine  April  21.  The  following  North  Carolenians  are  among 
the  number — Dr.  G.  A.  Caton,  Greensboro;  Dr.  R.  B.  Miller, 
Goldsboro;  Dr.  R.  J.  Price,   Wilmington. 

Surgeon-General  Van  Reypen,  of  the  Navy,  has  received 
over  three  hundred  offers  from  phys'cians  of  service  as  acting 
assistant  surgeons  in  the  Navy.  These  offers  cannot  be  accepted 
until  Congress  authorizes  the  temporary  appointment  of  acting 
surgeons.  There  are  about  twenty  vacancies  in  the  regular  ser- 
vice, for  which  there  are  few  or  no  applications  because    of  the 


gjg  NOTES    AND  ITEMS. 

humiliating  treatment  to  which  newly  appointed  assistant  sur- 
geons are  subjected.  If  Congress  will  remove  these  objectioanble 
features  and  will  authorize  the  appointment  of  acting  assistant 
surgeons,  there  will  be  no  lack  of  competent  men  for  vacancies. 
— Medical  Age. 

Medical  Officers  of  the  Army. — The  House  Committee  on 
Military  Affairs  has  made  a  favorable  report  on  the  House  bill 
providing  for  the  increase  of  the  number  of  medical  officers  in 
the  army  by  adding  15  assistant  surgeons,  with  the  rank  of  first 
lieutenant,  and  authorizing  the  surgeon-general  of  the  army, 
with  the  approval  of  the  Secretary  of  War,  to  appoint  as  many 
contract  surgeons  in  emergencies  as  may  be  necessary,  at  not 
exceeding  $150  per  month. — Philadelphia  Medical  Journal. 

Acting  Assistant  Surgeons. — Over  eight  hundred  medical 
men  have  offered  thir  services  to  the  army  authorities  and  more 
than  a  thousand  to  the  naval  medical  department.  These  are 
by  no  means  all  young  men  or  recent  graduates,  for  many  offers 
are  received  daily  from  men,  some  of  whom  saw  service  in  the 
civil  war  on  one  side  or  the  other,  and  others  who  have  come 
on  the  stage  since  that  time  but  who  stand  in  the  front  rank  of 
the  profession. — Medical  Record. 

Care  of  the  Sick  and  Wounded. — It  has  been  decided  that 
the  naval  ambulance  ship  Solace  shall  be  used  as  a  transport  for' 
the  sick  and  wounded  of  both  army  and  navy.  She  will  carry 
men  physicians  disqualified  for  active  service  from  the  fleet  or 
from  Cuba  to  Key  West  and  Tampa.  A  hospital  train  will  run 
from  Tampa  to  northern  points,  in  order  to  give  the  sick  a 
benfit  of  a  change  to  the  cooler  climate  of  the  middle  and  nor 
thern  Atlantic  seaboard.  A  general  army  and  navy  hospital 
will  be  established  at  Key  West,  and  hospital  tents  will  be  sent 
there  to  accommodate  any  overflow  of  incapacitated  seamen  and 
soldiers.  The  selection  of  Key  West  for  this  general  hospital  is 
due  chiefly  to  the  fact  that  the  island  is  more  healthful  than 
places  on  the  mainland,  in  the  event  of  a  fever  outbreak  among 
the  men  in  Cuba  or  on  tlie  warships,  the  treatment  of  the  stricken 
there  would  lessen  the  danger  of  a  spread  of  the  disease  to  the 
coast  proper.  Other  hospitals  are  to  be  established  in  the  depart- 
ment of  the  Gulf,  but  that  at  Key  West  will  be  the  headquarters 
of  the  medical  corps  of  both  military  services,  in  addition  to  the 
Marine  Hospital  service. — Medical  Record. 


YR.  HYPOPHOS.  CO.,  FELLOWS 

I  a  is  the  Esse  tial  ElementSof  the  AmmalOi-yanization— potash  and  Liim-: 


B  Oxidising  Agents Iion  and  Maganese: 

3  Tonics — Quinine  and  Strychnine; 


d  the  Vitalizing  Constituent — Phosphorus;  the  whole  combined  in  tlie  form 
of  a  Syrup  with  slightly  Alkaline  Bacteria. 

Differs  in  Its  Effects  from  all  Analogous  Preparations;  and  it  posses- 
sea  the  important  properties  of  being  pleasant  to  the  taste,  easily  borne  by  the 
stomach,  and  harmless  under  pi-olonged  use. 

as  Gained  a  Wide  Reputation  particularly  in  the  treatment  of  Pulmonary 
Tuberculosis,  Chronic  Bronchitis,  and  other  affections  of  the  respiratory  organs. 

vlt  has  also  been  employed  with  much  success  in  various  nervous  and  debilitating- 


Curative  Power  is  largely   attributable   to    its  stimulant,   tonic,  and  nutritive 

properties,  by  means  of  which  the  energy  of  the  system  is  recruited. 
Action  is  Prompt;  it  stimulates  the  appetite  and  the  digestion,  it  promotes  as- 
similation, and  it  enters  directly  into  the  circulation  with  the  food  products, 
prescribed  dose  produces  a  feeling  of  buoyancy,  and  removes  depression  and  mel- 
lOly:  hence  the  preparation  is  of  great  value  in  the  treatment  of  mental  and  nervous 
tions.  From  the  fact,  also,  that  it  exerts  a  double  tonic  inlluenee.  and  induces  a 
thy  flow  of  the  secretions,  its  use  is  indicated  in  a  wide  range  of  dL-ease::. 


NOTICE-CAUTION. 

'he  success  of  Fellows'  Syrup  of  Hypophosphites  has  tempted  certain 
ons  to  offer  imitations  of  it  for  sale.  Mr.  Fellows,  who  has  examined 
pies  of  several  of  these,  finds  that  no  two  of  them  are  identical, 
that  all  of  them  differ  from  the  original  in  composition,  in  freedom 
1  acid  reaction,  in  susceptibility  to  the  effects  ol  oxygen  wlien  ex- 
d  to  light  or  heat,  in  the  property  of  retaining  the  strych- 
e  in  solution,  and  in  the  medicinal  effects. 

s  these  cheap  and  inefficient  substitutes  are  frequently  dispensed  in- 
i  of  the  genuine  preparation,  physicians  are  earnestly  requested. 
n  prescribing  the  Syrup,  to  write  "Syr.  Hypophos.  Fellows." 
s  a  further  precaution,  it  is  advisable  that  the  Syrup  should  be 
red  in  the  original  bottles ;  the  distinguishing  marks  which  the  bot- 
(and  the  wrappers  surrounding  them)  bear,  can  then  be  examined, 
the  genuineness — or  otherwise — of  the  contents  thereby  proved. 


MEDICAL  LETTERS  MAY  BE  ADDRESSED  TO 

48  Vesey  Street,  New  York. 


Tablet 
Therapy 


iiiiiiiiiiii 


;^      LACTOPEPTINE  ^mL 

i  +      '"^-^  ^SGrainseacSr    ^^r^mf^m 

i  \  iactopfpilne  containsall known  Suliisfti^es?^^ 

*  V  cinp'oy*"'  by  Nalurf  intheDigesii<jn(Jidllf,#" 

i\         '  kinds offbod.     J':  v-:  >s#f 

^  ^  Supfriorloallo(hcrRemf(h'csrorp^:"#a 

L  V  pcpsia  Indigrslion  and  kindr<{l<Siil-;;i| 

^V  menis  (iwloDiges\iveD^^^^^ 

*r  Dost?  TO 4  U8UlS-inf « tACk^li"^' 

,  *  THf  KfW  rOM  WUdMKCH  «5K«fiii| 


Undoubtedly  stands 
high  in  the  professional 
estimation  at  the  pres- 
ent time,  and  justly  so 
on  account  of  the  many 
clinical  advantages 
which  it  possesses  as  a 
method  of  medication.  We  now  manuracture  Lactopeptine 
in  tablet  form  (fi^^e  grains  each)  and  to  still  further  increase 
their  therapeutic  efficiency,  we  have  added  a  small  quantity 
of  bromelin,  the  vegetable  digestive  ferment  recently 
isolated  from  pineapple  juice.  The  Lactopeptine  Tablet 
renders  it  easier  for  business  men,  or  those  who  are  away 
from  home  during  the  day,  to  carry  the  remedy  with  them 
in  a  convenient  form  for  administration  at  regular  intervals 
as  described  by  the  physician. 


Please  note  especially  that  each  tablet  is  plainly 
stamped  with  the  initials  N.  Y.  P.  A.  to  prevent  sub- 
stitution. 


Put  up  in  bottles  containing 

100  S-tr.  Tablets  and  50  -J-gr.  Tablets. 


|THF.R\'  riXES,  X.  €.,  i^  the  Be«t  Health  Renort  in  the 
South.    IVrite  to  J.   T.  PATRICK  for  Iiiroriiiatioii. 


^iit>  |.-lr«l    %>ar.  MAY    20,    1898.  Vol.    11     NO.    H». 

NORTH  CAROLINA 

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PYROCTIN  has  the  endorsement  of  the  Medical  Professi 
as  in  the  administration  it  exercises  no  depressing  effect  upon 
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Catalogue  sent  o\\  Application. 


NORTH  CAROLINA 

MEDICAL  JOURNAL, 


A  SEMI-MONTHLY  JOURNAL  OF  MEDICINE  AND 
SURGERY. 

Vol.  XLI.  Winston,   May  20,    1898.  No.   10. 


Society  *B?cport0. 


MEDICAL  SOCIETY  OF  THE  STATE  OF  NORTH 
CAROLINA. 

Forty-Fifth   Annual   Meeting  Held   in   Charlotte,  May  3,  4 
and  5,  1898. 

The  45  annual  meeting  of  the  Medical  Society  of  the  State  of 
North  Carolina  was  convened  in  the  Court  House  of  Charlotte, 
May  3,  1898.  President  Francis  Duffy,  of  Newbern,  in  the  chair. 

The  Society  was  called  to  order  by  Dr.  R.  J.  Brevard,  chair- 
man committee  of  arrangements. 

After  a  prayer  by  A.  D.  Barron,  D.  C,  C.  W.  Tillett,  Esq.,  of 
Charlotte,  made  the  following 

ADDRESS  OF   WELCOME. 

Ladies  and  gentlemen  of  the  North  Carolina  Medical  Society: 

The  first  thing  I  ever  saw  in  my  life  was  a  doctor.  It  seems 
that  he  had  promised  that  I  would  be  a  girl,  and  when  I 
arrived  on  the  scene  of  action,  he  was  very  much  disappointed 
and  looked  very  angry  at  me,  whereupon,  if  I  remember  aright, 
I  got  mad  and  twisted  up  my  little  face  and  hollered  at  him  as 
loud  as  I  could.  That  seemed  to  bring  him  to  his  senses  and 
he  apologized  and  said  I  was  a  fine  boy,  and  we  shook  hands  and 
from  that  day  to  this  I  have  been  on  the  most  excellent  terms 
with  the  doctors.  The  fact  is,  that  I  liked  them  so  well  that 
when  I  arrived  at  the  age  of  discretion  nothing  would   suit,  me 


-,l8  SOCIETY  HEPORTS. 

but  that  I  must  have  a  doctor's  daughter  for  my  wife!  You  will 
believe  me  then,  when  I  say  that  I  am  very  much  gratified  at 
the  honor  which  the  Medical  Society  of  this  city  conferred  upon 
rae  in  requesting  me  to  represent  them  in  extending  to  you  a 
most  hearty  welcome  for  them  and  in  telling  you^  h.ow  much  de- 
lighted the  whole  city  is  to  have  your  Society  meet  here.  The 
doctors  of  the  city  are  really  and  truly  glad  to  see  you,  and  if  the 
doctors  are  glad  to  see  you,  by  how  much  more  are  the  laymen 
pleased.  I  fear  it  will  be  difficult  for  me  to  tell  you  how  much 
pleased  the  laity  of  the  city  are  to  know  tnat  they  have  in  their 
midst  scores  of  the  foremost  physicians  of  the  State  making  us 
visits,  and  just  to  think  that  for  once  in  our  lives,  it  will  not  be 
$2  per  visit. 

Your  profession  as  physicians  and  ours  as  lawyers  are  closely 
identified.  We  meet  particularly  upon  the  common  plattorm  of 
medical  juris-prudence,  and  the  lawyers  have  often  to  call  upon 
the  doctors  as  witnesses  in  court.  Sometimes  we  have  one  doctor 
pitted  against  anothei  in  the  court  house  and  v.'hen  we 
have  battles  between  both  the  lawyers  and  the  doctors  at  the 
same  time  it  makes  a  very  interesting  occasion.  I  remember 
once  when  preparing  to  demolish  the  opposite  sidem  a  case,  I 
ran  up  my  torpedo  boat  in  the  shape  of  a  doctor  witness  close  to 
the  flag  ship  of  the  enemy  and  was  in  the  act  of  blowing  it  up 
as  I  thought,  when  all  of  a  sudden  there  came  up  on  my  flank 
in  the  shape  of  a  doctor  witness,  a  torpedo  destroyer,  and — 
well,  you  know  what  happened.  The  jury  of  investigation 
which  sat  on  the  case  brought  in  a  report  that  my  destruction 
was  accomplished  by  an  external  explosion  which  was  caused  by 
an  expert.  We,  of  the  legal  profession,  are  called  upon  from 
time  lo  time  to  study  almost  every  phase  of  the  Medical  Science 
in  the  preperation  of  our  cases  for  trial.  A  short  time  ago  we 
had  in  this  city  a  case  in  court  which  involved  the  question 
as  to  what  was  the  origin  of  malaria.  The  lawyers  borrowed 
from  the  doctors  all  of  the  medical  works  on  the  subject  of 
malaiia  that  they  could  and  studied  them  so  diligently  chat 
when  the  case  came  on  for  trial,  I  could  say  without  dis- 
paraging our  doctors,  that  the  lawyers  knew  as  much,  theo- 
retically speaking,  about  malaria  as  the  doctors  did.  In  fact  I 
heard  one  of  the  doctors  sav  that   the  next   case  of    malaria  he 


SOCIETY  REPORTS. 

had,  he  intended  to  call  in  one  of  the  lawyers  as  consulting  phy- 
sician. You  need  not  be  ahirmed  about  that  for  I  can  tell  you 
now  that  if  the  lawyer  should  undertake  to  prescribe  for  a  case 
of  malaria,  he  would  "fiing  it  into  fits"  and  then  you  would  get 
the  job  certain,  for  while  I  have  seen  lawyers  who  could  give  a 
man  fits,  I  never  saw  one  who  could  cure  it. 

Gentlemen,  the  city  of  Charlotte  is  yours,  and  all  that  we 
possess  while  you  are  here  is  at  your  command.  And  I  might 
pause  to  tell  you  into  what  great  possessions  you  have  come;  I 
might  tell  you  of  our  manly  men  and  womenly  women;  of  our 
pluck  and  enterprise;  of  our  many  and  diversified  industries;  of 
our  beautiful  streets  and  elegant  homes;  I  might  tell  you  that 
the  city  of  Charlotte  in  the  last  ten  years  has  more  than  doubled 
her  population,  and  has  forged  her  way  far  in  advance  of  any 
other  city  in  the  old  North  State;  but  I  am  afraid  to  bear  down 
too  heavy  upon  this  point  for  it  might  come  to  pass  that  about 
one-half  of  you  doctors  would  decide  to  locate  here  for  the 
practice  of  your  profession,  and  if  my  speech  should  accomplish 
such  a  result  as  that,  our  home  doctors  would  say  that  I  had 
over-done  the  thing,  and  they  would  never  invite  me  again  to 
deliver  their  address  of  welcome.  More  than  that  it  might  hap- 
pen that  you  would  go  home  and  tell  your  lawyer  friends  what 
I  had  said  about  the  greatness  of  Charlotte  and  they  too  would 
come  trooping  in  and  settle  here  to  divide  up  the  law  practice 
which  is  already  subjected  to  long  division.  So  it  has  been 
suggested  to  me  that  I  hint  to  you  in  a  round  about  way  that 
while  Charlotte  is  undoubtedly  a  thrifty  and  popular  city  it  is 
also  an  exceedingly  healthy  oae.  But  I  might  as  well  be  frank 
with  you  gentlemen  and  say  witout  any  circumlocution  that 
while  we  are  more  than  glad  to  have  you  here  and  hope  that  you 
will  have  a  delightful  time,  still  we  do  not  expect  you  to  spend 
your  life  time  in  our  midst. 

Gentlemen,  as  I  have  already  said  the  city  is  yours,  and  I 
would  like  to  suggest  that  the  motto  for  the  assemblage  be  this 
"If  you  do  not  see  what  you  want,  ask  for  it."  It  is  said  that 
among  the  Fallaheens  of  the  Desert,  noted  for  their  unbounded 
hospitality,  it  is  not  considered  proper  to  ask  a  guest  to  partake 
of  anything  at  all,  until  he  fi'-st  signifies  that  he  wishes  it,  but 
when  the  request  is  once  made  by  the  guest  the  thing  asked  for, 
must  be  had  at  once  and  at  all  hazards.     An  artist   writer  tells 


^20  SOCIETY  REPORTS. 

the  Story  that  he  recently  visited  a  shiek  of  the  Fallaheens  and 
went  out  one  morning  to  paint  a  picture  of  a  quaint  and  beauti 
ful  cemetery  when  he  said  to  the  Shiek  at  his  side;  "This  is  a 
most  beautiful  scene  for  a  picture  but  one  thing  is  lacking." 
"What  is  that?"  asked  the  Shiek.  The  artist  replied;  "It  lacks 
a  funeral  procession  coming  in  to  bury  the  dead'  to  make  the 
picture  complete."  "Hold  on"  said  the  Shiek  "I  know  a  man 
in  the  village  who  is  about  to  die,  and  I  will  go  and  hurry  him 
up."  Before  the  artist  could  lemonstrate,  the  Shiek  was  off  and 
created  such  a  bluster  and  excitement  around  the  sick  man's 
house  that  he  died  in  a  few  minutes,  and  in  less  than  two  hours 
the  Shiek  had  a  genuine  funeral  procession  going  to  the  cemetery 
and  the  artist's  picture  was  complete.  Gentlemen,  look  around 
you,  if  you  do  not  see  what  you  want,  ask  for  it.  Go  down  to 
our  beautiful  cemetery  and  if  you  decide  you  would  like  to  see 
how  we  bury  oui  dead,  I  can  assure  you  that  any  of  our  home 
doctors  can  get  up  a  funeral  in  a  very  short  time.  But  I  should 
apf.ligize  for  that.  I  have  been  told  that  it  is  not  good  form  to 
speak  of  funerals  in  the  presence  of  doctors.  They  say  that  it 
is  an  embarrasing  subject  and  I  am  really  sorry  that  I  had  any- 
thing to  say  about  it. 

I  trust  that  while  you  are  here  that  the  members  of  your  So- 
ciety will  enjoy  good  health,  but  if  any  of  you  get  sick  I  should 
like  to  know  of  it, — Not  only  because  I  desire  to  show  attention 
to  a  sick  guest,  but  for  the  additional  reason  that  I  desire  to 
know  if  a  sick  doctor  takes  any  medicine.  There  is,  you  know, 
a  deep  seated  conviction  that  you  doctors  do  not  take  any  of 
your  own  medicine.  So  far  as  my  own  experience  goes  I  can 
say  that  while  I  have  seen  doctors  taste  medicine  and  smeli 
medicine,  I  have  never  seen  one  take  a  bona  fide  dose  of  it. 
Since  I  have  resided  in  Charlotte,  I  have  sat  up  all  night  with 
two  of  our  most  prominent  physicians  who  were  sick,  and  I  can 
only  say  that  according  to  my  recollection,  I  never  saw  either 
one  take  a  single  drop  of  medicine.  Charles  Dickens  more 
than  fifty  years  ago  called  attention  to  this  fact  that  doctors  do 
not  take  medicine.  It  is  true  that  he  said  something  in  this 
same  connection  about  lawyers  not  having  lawsuits,  and  said 
that  "lawyers  were  shy  ot  meddling  with  the  law  on  their  own 
account,  well  knowing  that  it  was  an   edged   tool  of    uncertain 


SOCIKTY   REPORTS. 

application,  and  very  expensive  in  its  operation  and  rather  re- 
markable for  its  properties  of  close  shaving  than  of  always 
shaving  the  right  person."  But  that  was  a  fling  at  the  lawyers 
that  was  unworthy  of  Dickens  and  I  will  take  occasion  to  refute 
it  at  some  other  time.  I  am  impressing  you  now  with  what  he 
said  about  doctors,  and  if  what  he  said  is  not  true  I  would  like 
for  you  to  refute  it  and  if  it  is  true  I  would  like  for  you  to  ex- 
plain it. 

And  just  here  comes  a  part  of  my  speech  which  it  seems  to  me 
I  will  have  to  omit.  I  had  begun  the  preparation  of  this  while 
the  president  was  about  to  call  for  volunteers  and  I  expect  about 
one-half  or  you  doctors  would  respond  to  the  call  and  that  your 
meeting  would  be  a  sad  one  owing  to  the  absence  of  members 
who  had  gone  to  Cuba.  I  had  prepared  some  very  touching 
remarks  which  I  thought  well  calculated  to  bring  you  to  tears 
but  as  I  find  that  your  ranks  are  still  intact  I  think  that  part  of 
my  speech  would  fall  flat  and  I  will  have  to  omit  it  and  ask  leave 
to  print  it.  Of  the  crowd  that  went  from  this  place  on  yester- 
day, only  one  doctor  went  and  only  one  lawyer,  and  he  was 
from  a  distant  county,  all  of  which  goes  to  show  tliat  the  doctors 
and  the  lawyers  are  not  anxious  to  get  in  the  way  of  the  enemy's 
bullets.  I  am  reminded  of  the  stoi'y  of  a  great  orator  who  just 
before  the  breaking  out  of  the  last  war  was  exhorting  the  men 
of  his  audience  to  fight  and  die  for  their  country,  and  in  the 
climax  he  quoted  that  beautiful  line  from  Horace:  ''''Dulce  et 
decorum  est patria  mori"  ;  whereupon  one  of  his  auditors  arose  and 
asked  the  speaker  that  if  it  was  such  a  sweet  and  honorable  thing 
to  die  for  one's  country,  why  he  did  not  go  to  the  front.  "That" 
said  the  orator  "is  very  easily  explained,  I  never  was  fond  of 
sweet  things!"  And  gentlemen,  while  we  all  agree  that  it  is 
sweet  to  die  for  one's  native  land,  not  many  of  us  appear  to  be 
fond  of  sweet  things. 

But  speaking  seriously  there  is  no  body  of  men  in  all  the  State 
that  could  present  a  more  interesting  spectacle  than  this  Medical 
Society.  I  say  this,  not  only  because  the  men  before  me  are 
men  of  education,  position,  and  men  whose  whole  livss  in  a 
measure  are  devoted  to  charity,  and  good  works  but  I  am  proud 
of  you  because  of  your  fidelity  and  ability  in  your  profession. 
I  see  before  me  men  in  whose  breasts  are  locked  up  the  secrets 


^■2  2-  SOCIETY  ETiPORTS: 

of  hundreds  of  homes  throughout  the  country.  It  is  said  that 
there  is  a  skeleton  in  every  closet,  and  if  so,  it  happens  ninety- 
nine  times  in  a  hundred  that  the  tamily  physician  is  the  only- 
outsider  who  has  ever  looked  upon  that  skeleton.  If  the  seal 
upon  your  lips  were  broken  and  you  were  to  tell  the  plain  facts 
within  your  knowledge  of  the  family  secrets  you-  know  there- 
would  be  a  con-^sternation  all  over  the  State  a  thousand  fold 
greater  than  that  caused  by  the  blowing,  up  of  the  Maine.  More- 
than  that  you  go  in-to  the  innerm-ost  recesses  af  our  homes.  You 
are  admitted  where  r^one  but  the  doctor  can  go  and  have  about 
you  opportunities  not  to  say  temptations  to  wrong,,  and  Isay  all' 
gloiy  to  the  Medical  Society  of  North  Carolina,  for  while  doctors- 
of  other  States  have  wrecked  homes  and  broken  hearts  there  is 
not  a  member  of  this  Society  so  far  as  I  know  who  has  been, 
guilty  of  a  breach  of  professional  confidence. 

But  gentlemen  the  thing  that  moves  me  most,  as  I  look  into- 
your  earnest  faces  to  day,  is  the  thought  of  what  you  have  been 
through  since  last  you  met.  I  love  to  look  at  the  ragged  lem- 
nant  of  the  old  regiment  an^d  it  stirs  me  to  think  of  the  awful 
battles  and  fierce  conflicts  through  which  they  have  come,  but 
these  men  fought  with  enemies  of  flesh  and  blood  like  themselves 
while  the  batallion  which  I  see  before  me  has  been  in  daily  con 
fiict  with  the  most  fearful  foe  of  mankind.  In  the  grav  dawn 
of  the  morning,  in  the  heat  of  the  noonday  sun,  through  the  long 
weary  watches  of  the  night,  in  the  mountain  fastnesses  of  the 
West,  in  the  boggs  and  marshes  of  the  eastern  plains,  anywhere, 
eveiy where,  you  have  pursued  the  Rider  of  the  Pale  Horse. 
Sometimes  you  have  seen  him  bearing  his  victim  in  the  distance 
down  into  the  shadows  of  the  great  darkness  and  you  have 
hotly  pursued  him  to  where  the  gates  of  death  were  creaking  on 
their  black  hinges  to  let  him  in  and  you  seized  him  and  brought 
him  back  to  light  and  life  and  health  again. 

The  men  here  who  have  had  the  most  awfuf  conflicts  are,  I 
doubt  not,  the  country  doctors  G'^d  bless  the  country  doctors! 
The  whole  world  and  particularly  the  medical  profession  owe 
Ian  Maclaren  a  debt  of  unmeasureable  gratitude  for  telling  us 
of  William  McLure  and  how  he  lived  and  how  he  died.  1  doubt 
not  that  some  country  doctor  here  has  been  in  hand  to  hand 
battles  with  the  dread  enemy  of  mankind  and  far  away  in  the 
country,  twenty-five  miles  it  may  be  from  any  brother  physician, 


Boic'iETY  K>:i'(:mTs.  » 2  3 

all  night  long,  he  has  fought  alone  the  "fight  for  life"  as  brave 
A  heart  and  as  true  a  nerve,  as  beat  in  the  hearts  of  the  Light 
Brigade  at  bloody  Balaklava. 

Gentlemen,  I  am  fully  persuaded  that  the  world  does  not 
know  one  half  of  what  it  owes  to  your  Medical  Society.  The 
man  of  average  intelligence  knows  who  the  great  warriors,  the 
great  explorers,  orators,  the  scientists  of  the  world  have  been, 
but  very  few  indeed  know  who  the  great  doctors  are,  and  what 
they  have  done  for  mankind.  There  are  a  hundred  men  who 
know  David  Livingstone,  explorer,  to  one  that  knows  William 
Harvey,  doctor;  and  yet  when  Harvey  discovered  the  circula- 
tion of  the  blood  and  that  the  heart  was  the  source  from  which 
it  was  pumped  forth  and  back  again,  he  did  a  thousand  fold  more 
for  humanity  than  did  Livingstone  when  he  discovered  the  source 
of  the  Nile,  and  brought  to  light  the  wonders  of  darkest  Africa. 
There  are  a  hundred  men  who  know  the  Duke  of  Wellington, 
warrior,  to  one  that  knows  Edward  Jenner,  physician,  and  yet 
no  one  can  deny  that  when  Jennor  put  small-pox  to  flight  with 
a  drop  of  vaccine,  that  he  did  a  thousand  fold  more  for  humanity 
than  did  the  Iron  Duke  when  he  swept  the  proud  Corsican  and 
the  Imperial  Guard  from  the  fateful  field  of  Waterloo.  Gentle- 
men, the  world  knows  of  its  other  heroes  and  why  should  it  not 
know  of  the  heroes  of  medicine.  You  owe  to  the  world  and  to 
the  great  men  of  your  profession  who  have  wr  jught  such  won 
ders,  to  keep  their  deeds  ever  in  the  remembrance  of  the  men. 
You  should  call  the  roll  of  the  great  doctors  from  time  to  time 
and  tell  of  their  beneficent  deeds.  I  commend  to  you  the 
beautiful  way  in  which  the  Peruvians  keep  alive  the  memory  of 
one  of  their  great  warriors.  In  the  war  with  Chili  the  naval 
commander  of  the  Peruvians  was  Admiral  Grau,  as  brave  an 
officer  as  ever  commantled  a  fleet.  In  his  last  battle  he  com- 
manded the  the  iron  clad  Huascar.  It  was  engaged  in  deadly 
conflict  war  Chillian  vessel  and  was  about  to  sink  her  when 
another  Chillian  vessel  came  up  on  the  other  side  of  the  Huascar 
and  poured  into  her  a  perfect  hell  of  shot  and  shell.  The  coura- 
geous Grau,  not  seeking  a  place  of  safety  and  not  contemplating 
surrender,  went  aloft  where  the  dangers  were  the  thickest  but 
where  he  could  best  give  his  command.  Above  the  din  and  roar 
of  battle  his   clarion   voice    was   heard    giving  commands,    but 


-24,  SOCIKTY  REPORTS. 

finally,  it  was  hushed.  An  officer  going  aloft,  found  the  lifeless 
body  stretched  upon  the  floor,  his  head  severed  as  tho'  ampu- 
ated  by  a  surgeon's  knife.  Does  Peru  allow  his  name  to  be  for- 
gotten? Not  so,  but  they  tell  that  on  every  muster  day,  tho' 
the  brave  admiral  has  been  dead  for  twenty  years,  his  name  is 
the  first  to  be  called  on  the  roll,  and  when  the  name  of  Admiral 
Miguel  Grau  is  called  an  officer  steps  farward  and  taking  off  his 
cap  points  with  one  hand  above  and  answers:  "Absent  but  ac- 
counted for,  he  is  among  the  heroes!"  I  commend  to  you  gen- 
tlemen, this  beautiful  story  and  ask  that  from  time  to  time  in 
your  Society  you  call  the  roll  of  those  who  have  done  so  much 
in  alleviating  the  woes  and  sorrows  of  suffering  humanity,  and 
let  some  one  rise  and  tell  afresh  the  story  of  their  greatness. 

Dr.  J.  Howell  Way,  made  the  following 
RESPONSE. 

On  behalf  of  my  confreres  of  the  North  Carolira  State  Medical 
Society  I  thank  you  most  sincerely  for  the  eloquent  words  of 
gracious  welcome  to  which  we  have  just  listened.  And  in  doing 
so,  it  is  with  regret  that  for  the  present  moment  at  least,  I  can- 
not lose  my  personality  as  a  plain  country  doctor  more  given  to 
work  and  action  than  to  the  evolution  and  delivery  of  eloquent 
words  or  oratorically  turned  phrases,  and  become  endowed  with 
the  gifted  tongue  of  a  Depew  or  a  Grady;  so  needful  were  I  to 
essay  to  express  in  language  our  appreciation  of  your  cordial 
reception. 

The  members  of  the  Medical  Society  are  no  strangers  to  the 
splendid  hospitality  that  has  ever  been  a  characteristic  of  the 
noble  sons  and  gifted  daughters  of  Mecklenburg.  Twice  before 
in  the  forty-nine  years  of  our  Society's  existence  have  we  been 
your  honored  guests.  In  1874,  near  a  quarter  of  a  century 
ago,  the  doctors  knocked  at  your  hospitable  gates  and  were 
made  welcome.  Upon  which  memorable  occasion,  your  spokes- 
man, that  most  illustrious  of  Carolina's  sons,  the  immortal 
Vance,  after  assuring  us  that  we  were  thrice  welcome,  and  plac- 
ing at  our  entire  disposal  the  homes,  the  property,  and  all  other 
of  the  material  valuables  of  your  charming  city,  in  return  only 
gravely  asked  that  we  permit  you  to  escape  with  your  lives. 

Again  in  1887,  it  was  the  happy  fortune  of  the  Society  to 
visit  you  when    the  agreeable  experiences   of   the    former   visit 


SOCIFrY  REPORTS.  «2C 

were  more  than  repeated.  And  now  in  this  year  of  grace,  1898, 
an  experiencing  the  charms  of  our  third  visit  we  feel  that  most 
opportune  is  our  selection  of  the  Queen  City  for  our  annual 
convocation.  Queen  City^  sir,  not  only  in  that  it  is  named  for 
the  beautiful  princess  Charlotte  of  Mecklenburg,  but  Oueen 
City  in  that  Charlotte  stands  pre-eminent  among  the  cities  of 
our  loved  State  in  her  civic  pride,  in  her  progressive  spirit,  in 
her  constant  upward  and  onward  march  toward  the  goal  of  all 
that  makes  a  municipality  great  and  powerful  and  its  citizens 
respected;  pre-eminent  in  the  cultivation  in  the  bosoms  of  its 
noble  population  of  that  love  of  virtue,  of  patriotism,  and  of 
liberty  which  has  ever  been  the  .priceless  heritage,  and  as  ever 
the  constant  attributes  of  her  manly  sons  and  beautiful 
daughters. 

Opportune  indeed  is  our  assembling  here  upon  the  historic 
site  of  Old  Queen's  Museum  in  Mecklenburg,  within  a  few  days 
of  the  unveiling  of  that  splendid  shaft  of  granite  which  rising 
heavenward  shall  stand  an  object  lesson  in  patriotism  to  the 
children  of  future  generations,  inculcating  them  with  love  of 
country  and  respect  for  the  heroic  deeds  of  their  illustrious  an- 
cestors; and  forever  immortalizing  the  distinguished  bravery, 
and  the  pure  patriotism  of  those  noble  sons  of  Carolina,  who  in 
the  dark  and  troublous  days  of  i  775,  gathered  here  and  hung 
out  to  the  enlightenment  of  the  world  the  beacon  light  of  lib- 
erty that  cast  the  first  luminous  rays  across  the  American  Con- 
tinent dispelling  the  universal  darkness  of  oppression  enshroud- 
ing the  new  world.  In  passing,  it  thrills  the  patriotic  impulses 
of  all  hearts  to  note  that  the  spirit  of  1775  still  lives  in  the  hearts 
of  the  American  people,  and  that  it  shall  animate  them,  in  noble 
emulation  of  our  gallant  Southern  Fitz  Hugh  Lee,  and  Dewey 
the  peerless  of  Manilla  Bay,  (applause)  to  continued  patriotic 
action,  which  will  see  no  end  until  Cuba  Libre  breathes  the 
sweet  air  of  freedom,  and  the  now  faint  and  glimmering  light 
of  her  one  struggling  star  shall  have  its  effulgence  brightened 
and  beautified  as  it  blends  into  the  forty-sixth  in  the  grand  con- 
stellation of  the  States  of  the  great  American  republic. 

I  refer  to  these  things  knowing  as  I  do,  that  in  the  hearts  of  no 
class  of  our  citizens  is  there  a  greater  degree  of  patriotism  than 
in  those  of  the  members  of  the  medical  profession.     No  portion 


^26  SOCIETY  REPORTS . 

of  our  citizens  are  in  so  intimate  a  social  contact  with  all  classes 
and  conditions  of  society  as  the  doctor  in  his  daily  rounds  dis- 
pensing mercy's  kindly  ministrations,  into  the  homes  of  the 
rich  aand  poor,  the  high  and  low,  the  strong  and  the  weak,  the 
learned  savant  and  the  illiterate.  The  saint  and  the  sinner 
alike  receive  his  attention,  none,  so  low  the  doctor  will  not,  in 
humble  imitation  of  the  Great  Physician,  stoop  to  succor;  none 
so  high  his  service  can  dispense  with.  Whether  in  the  luxurious 
offices  of  the  opulet  metropolitan  consultant,  a  Gross,  a  Flint, 
an  Agnew,  or  a  Sir  Andrew  Clark,  or  as  the  Carolina  prototype 
of  good  old  Doctor  MacLure,  of  Drumtochty  fame,  plodding 
along  the  banks  of  the  Cape  Iiear  or  Catawba,  or  the  more 
sparkling  waters  of  the  Swannannoa  or  Pigeon,  as  an  humble 
country  doctor — where  ere  his  lot  be  cast,  the  doctor  lives  in 
closest  sympathy  with  humanity,  and  that  which  touches  his 
fellow-man  alike  impresses  him. 

Is  it  to  be  wondered  at  that  the  family  physician  should  be 
the  chosen  trusted  friend?  And  this  close  confidential  relation 
around  the  sanctity  of  which,  both  the  law  of  the  land  and  the 
unwritten  higher  law  of  public  sentiment,  has  thrown  a  veil 
through  which  no  curious  or  peering  eyes  may  its  secrets  dis- 
close, imposes  upon  the  members  of  our  profession  weighty  re- 
sponsibilities and  important  duties  to  be  most  seriously  con- 
sidered. How  well  we  have  in  North  Carolina  discharged  these 
responsibilities  in  the  past,  our  magnificent  and  splendidly  offi- 
cered institutions  for  the  care  of  society's  unfortunates;  our 
State  Board  of  Medical  Examiners  (the  model  from  which  almost 
every  other  State  in  the  Union  is  now  copying!),  our  State, 
county  and  municipal  boards  of  health;  our  laws  regarding  epi- 
demics and  the  regulations  affecting  contagious  and  infectious 
disease;  the  general  and  constant  dissemination  of  v  duable  in- 
formation among  the  people  upon  the  vital  subject  of  how  best 
to  live,  to  promote  health,  to  attain  longevity — the  resultant 
ever  increasing  length  in  the  average  of  human  life — all  these 
attest  whether  our  physicians  have  well-borne  the  weightier 
responsibilities  imposed  on  them  by  society  at  large  and  by  the 
State! 

But  Sir,  I  stand  not  here  todaj^  to  express  to  you  extreme 
laudation  of  the  North  Carolina  doctors  for  the  honesty  of  pur- 


SOCIETY  REPORTS. 

pose  and  the  sincerity  of  action  which  have  ever  been  the  com- 
mcn  characteracteristics  of  the  members  of  our  most  noble  of 
professions.  Nor  is  it  my  province  to  indulge  in  fulsome  eulogy 
of  the  energy,  the  progressiveness,  the  public-spiritedness,  or 
the  bravery,  of  the  chivalrous  sons,  nor  the  grace,  the  wit,  the 
beauty,  the  lovliness,  or  the  true  feminine  worth  of  the  accom- 
plished daughters,  of  Mecklenburg.  All  these  things  are  known 
of  all  men,  for  them  your  men  are  everywhere  respected  and 
honored,  your  lovely  women  alike  adored  and  worshiped. 

I  thank  you  in  the  name  of  my  colleagues  for  your  most  gen- 
erous welcome,  and  assure  you  that  as  we  return  to  our  homes 
a  day  or  two  hence  to  resume  the  active  duties  and  the  varied 
responsibilities  of  our  busy  professional  lives,  that  each  of  us 
will  carry  away  from  Charlotte,  ineffably  imprinted  upon  our 
hearts,  a  most  pleasant  remembrance  of  the  Queen  City  and  her 
truly  regal  people. 

The  roll  was  then  called  by  the  Secretary.  Members  present 
will  be  indicated  in  alphabetical  list  of  members. 

The  following  committees  were  appointed  :  On  Credentials, 
Drs.  J.  C.  Montgomery,  T.  M.  Jordan,  and  A.  A.  Kent.;  on 
Finance,  Drs.  C.  M.  Poole,  Albert  Anderson,  and  R.  L.  Gibbon. 

Dr.  J.  S.  Browm,  chairman  of  section  on  Medical  Jurispru- 
dence and  State  Medicine  read  his  report.  Discussed  by  Drs. 
Long,  Burroughs,  McMullan,   and  Carr. 

Dr.  Carr  offered  the  following  resolution: 

Resolved,  That  the  Medical  Society  of  North  Carolina,  in 
convention  assembled  in  the  city  of  Charlotte,  May  3,  1898,  ex- 
presses its  unqualified  disapproval  of  the  Antivivisestion  Bill, 
now  pending  before  Congress,  and  that  the  President  of  this 
Society  appoint  a  committee  of  three  to  memorialize  our  Senators 
and  Representatives  in  Congress  to  use  all  honorable  means  to 
defeat  its  passage. 

The  President  appointed  on  this  committee,  Drs.  A.  G.  Carr, 
G.  W.  Long  and  P.  E.  Hines. 

Di.  W.  T.  Pate,  Chairman  of  section  on  Pathology  and 
Microscopy,  made  his  report. 

On  motion  the  Society  adjourned  to  meet  at  3:30  o'clock. 


^28  SOCIETY  REPURTS'. 

FIRST  DAY— AFTERNOON'. 
Dr.  H;  S.  Lott,  read  a  pap>er  entitled 

ISJKDDLESOME    GYNEC  A  LOC.V  . 

Discussed  by  Drs.  McMuUan,  McGuire,  Sik-es  and  Roysten 
Dr.  Fletcher,  Chairman  oi  section   on   Fractlce   of   Medicine, 
made  his  report. 

Dr.  W.  C.  Brovvnson  read  a  paper  o-o 

THE    TOBACCO    HABIT    AS-   A-    CAUSE    O-F    MSEASE-. 

DV.  J.  A.  Burroughs,  Leader  of  Efebste,.  operred  the  Annu-al 
Discussion  by  reading  a  well  prejjared  paper  ewtitkd 

A   FEW   SUGGESTIONS  ON   THE  PREVENTION   OF   TUBERCULOSIS. 

Drs.  A.  A.  Ken-t,  R.  H,  Lewrs,  J.  W.  Long,  J.  A.  Reagan,, 
Albert  Anderson,.  Speneer  anrd  others  took  part  in  the  decision. 

Dr.  G.  S.  Tennant  read  a  paper  on  Uric  Acid  in.  the  Causatiora 
of  Retinal  and  Choroidal  Disease, 

On  motion,  the  Society  adjoarned. 


FIRST  DAY— EVENING  SESSION. 

Dr.  W.  G.  Stafford,  Chairman  of  Section  on  Obstetrics,  made 
his  report. 

Dr.  H.  S.  Lott  read  a  paper  on  ""Treatmer/t  of  Umbilical 
Cord  without  Ligature."  Discussed  by  Drs.  Stafford,  Bur- 
roughs, Hays,  Hines,  McMuUan,  O'Hagan,  and  Kent. 

Dr,  E.  F.  Strickland  read  a  paper  on  "Three  Interesting 
Cases  oi  Obstetrics." 

Dr.  J.  P.  Munroe  presented  a  paper  entitled  '"Some  Obser- 
vations on  the  Radical  Cure  of  Inguinal  Hornia,  with  Report 
of  an  Interesting  Case."  At  the  close  of  his  paper  be  presented 
stereopticon  pictures  illustrating  the  various  steps  in  the  opera- 
tion'.     Dr.  Plippin  discussed  the  paper. 

The  Society  adjourned  to  meet  the  next  morning  at  lo  o'clock. 


SECOND  DAY— MORNING  SESSION. 

The  Society  met  at  lo  o'clock  and  was   called  to  order  by  the 
President,  who  appointed  the  following  nominating  committee: 


SOCIETY  REPORTS.  -^ 

Drs.    O'Hagan,   W.  H.    H.  Cobb,  W.   P.  Ivey,  A.  G.  Carr,  and 
H.  H.  Dodson. 

Dr.  R.  L.  Payne  read  a  paper  on  Abortion,  which  was  dis- 
cussed by  Drs.  Hines  and  Jordan. 

Dr.  Long  made  the  following  report  on   President's  Address: 

Your  Committee  appointed  to  take  into  consideration  the 
suggestions  contained  in  the  President's  Address,  desire  to  re- 
port as  follows.  We  approve  the  following  suggestions:  An 
earlier  meeting  of  the  Medical  Examining  Board  in  order  that 
its  licentiates  may  have  an  opportunity  of  joining  the  Society, 
and  as  a  further  inducement,  we  heartily  recommend  that  the 
usual  initiation  fee  ($5.00)  be  remitted  to  those  licentiates  who 
join  the  State  Medical  Society  the  same  year  that  they  receive 
their  licenses.  Furthermore,  as  cognate  to  this  subject  and  in 
order  that  we  may  enlist  the  sympathy  of  all  legal  practitioners 
of  the  State,  we  recommend  that  any  such  physicians  who  shall 
be  vouched  for  by  the  physicians  already  members  of  this  So- 
ciety, and  who  shall  accompany  his  application  with  the  usual 
five  dollar  fee  and  shall  sign  the  Constitution  by  power  ot  at- 
torney invested  in  one  of  the  recommending  physicians  shall  be 
eligible  for  membership,  provided  such  action  be  confirmed  by 
a  majority  of  the  Society.  R.  J.  BREVARD, 

OSCAR    McMULLAN, 
GEO.  W.  LONG. 

Action  on  the  report  was  postponed. 

Dr.  C.  L.  Minor  read  a  paper  entitled  "What  Should  be  the 
Attitude  of  the  Profession  towards  Serum  Therapy."  Dis- 
cussed by  Dr.  Burroughs,  Dr.  Levy,  of  Virginia,  Dr.  Reynolds. 

The  time  having  arrived  for  the  special  order  of  electing  two 
members  to  the  Board  of  Examiners  to  fill  the  places  of  Dr. 
Weaver  and  Dr.  Baker,  whose  terms  expired  with  this  meeting. 
Drs.  Albert  Anderson,  E.  C.  Register  and  M.  H.  Fletcher  were 
put  in  nomination.  Drs.  H.  A.  Royster,  T.  S.  McMuUan,  A. 
J.  Crowell,  and  B.  K.  Hays  were  appointed  tellers,  the  vote  was 
taken,  and  Drs.  Anderson  and  Register  were  elected,  both  hav- 
ing received  a  majority  of  the  votes  cast. 

On  motion  of  Dr.  J.  Allison  Hodges,  the  following  were 
made  honorary  fellows  of  the  Society,  having  been  active  mem- 
bers of  the  Society  for  thirty  years  or  more:  Dr.  Robert  Gib- 
bon, Dr.  Allman  Holmes,  Dr.  Peter  E.  Hines,  Dr.  R.  H.  Win- 
borne,  Dr.  Geo.  A.  Foote,  Dr.  Eugene  Grissom,  Dr.  W.  J. 
Jones,  Dr.  Chas.  J.  O'Hagan,  Dr.  J.  W.  Jone?,  Dr.  J.  K.  Ruf- 
fin.  Dr.  Wm.  R.  Wood,   Dr.  P.  A.  Barrier,   Dr.  Geo.  L.  Kirby, 


^-,0  ,  SOCIETY  REPOKTS. 

Dr.  J.  F.  Shaffner,  Dr.  W.  T.  Cheatham,  Dr.  F.  J.  Haywood, 
Dr.  P.  B.  Alston. 

On  motion  of  Dr.  O'Hagan,  Dr.  W.  L.  Robinson,  of  Dan- 
ville, Va.,  was  elected  an  Honorary  member  of  the  Society. 
Dr.  Robinson  accepted  the  courtesy  in  a  few  well  chosen  re- 
marks. 

The  special  hour  having  arrived,  the  Conjoint  Session  of  the 
Board  of  Health  was  called,  and  in  the  absence  of  the  Presi- 
dent, Dr.  S.  Westray  Battle  took  the  chair.  The  Secretary  read 
his  report,  which,  after  a  full  discussion,   was  ordered   printed. 

Dr.  R.  H.  Lewis  offered  the  following  resolution,  which  was 
adopted: 

Resolved,  That  the  North  Carolina  Board  of  Health  and  the 
Medical  Society  of  the  State  of  North  Carolina  in  conjoint  ses- 
sion assembled  endorse  the  Caffery  bill,  enlarging  the  powers  of 
the  U.  S.  Marine  Hospital  Service,  and  respectfully  request  our 
Senators  and  Representatives  to  support  the  sam.e. 

The  session  was  then  adjourned. 


SECOND  DAY— AFTERNOON  SESSION. 

The  Society  was  called  to  order  by  the  President. 

A  paper  on  "A  Case  of  Osteo-Sarcoma  Treated  with  the 
Toxins  of  Erysipelas  and  Bacillus  Prodigiosus"  was  read  by 
Dr.  J.  C.  Walton,  of  Reidsville.  Discussed  by  Dr.  Robinson 
and  Dr.  Jewett. 

Dr.  K.  P.  Battle  then  read  a  paper  on  "A  Shawl  Pin  in  the 
Trachea."  Discussed  by  Dr.  Galloway,  Dr.  Payne,  Dr.  Carr, 
Dr.  Fai.son,  and  Dr.  Costner  and  others  who  cited  cases  in 
point. 

Dr.  R.  H.  McGinnis  read  a  paper  on  "Some  Thoughts  about 
Typhoid  Fever."  By  request,  Dr.  Taylor  of  Richmond  dis- 
cussed the  surgery  of  typhoid  fever. 

The  selection  of  place  of  next  meeting  being  next  in  order, 
Asheville,  Fayetteville,  Wilmington,  and  Newbern  were  put  in 
nomination.  Asheville  was  selected,  and  on  motion  of  the 
Society,  the  choice  was  made  unanimous. 

The  Society  then  proceeded  to  election  of  officers.  The  name 
of  Dr.  L.  J.  Picot  for  President  was  put  in  nomination,  and  Dr. 


SOCIETY  REPORTS. 

C.  M.  Poole  was  instructed  to  cast  the  vote  of    the    Society  for 
Dr.  Picot. 

The  following  Vice  Presidents  were  nominated,  and  on  mo- 
tion, the  Secretary  cast  the  vote  of  the  Society  for  them,  ist, 
I.  W.  Faison,  Charlotte;  2nd,  H.  H.  Dodson,  Milton;  3rd,  J. 
W.  White,  Wilkesboro;  4th.  W.  C.  Brownson,  Asheville. 

Drs.  G.  W.  Pressley,  R.  D.  Jewett  and  H.  A.  Royster  were 
put  in  nomination  for  Secretary.  By  request  of  Dr.  Jewett  his 
name  was  withdrawn.  Drs.  Sikes  and  Fletcher  were  appointed 
tellers,  the  vote  was  taken,  and  Dr.  Pressley  was  declared 
elected  by  a  plurality  vote. 

For  Treasurer,  Dr.  G.  T.  Sikes  and  Dr.  T.  M.  Jordan  were 
■  put  in  nomination.  Dr.  Fletcher  and  Dr.  Nicholson  were  ap- 
pointed tellers,  the  vote  was  taken,  and  Dr.  Sikes  was  elected. 
Dr.  Weaver,  Secretary  of  the  Board  of  Medical  examiners  re- 
ported the  following  successful  applicants  for  license  and  on 
motion  they  were  referred  to  tlie  committee  on  Credentials:  J, 
A.  Williams,  J.  T.  Stewart,  J.  T.  Burros,  N.  G.  Shaw,  R.  S. 
Rierson,  J.  B.  Hunter,  F.  T.  Long,  R.  E.  Jenkins,  W.  R.  Mc- 
Cain; G.  F.  Duncan,  Walter  Jackson  Jones,  Thomas  Spring- 
field, J.  E.  Moore,  John  Davidson,  W.  A.  Rogers,  G.  A.  Canton, 
J.  H.  Mock,  R.  D.  Flippin,  W.  L.  Query,  J.  D.  Williams,  J.  I. 
Campbell,  Herbert  B.  Thomas,  J.  E.  Kerr,  H.  D.  Stewart,  G. 
A.  Stevens,  F.  H.  Gilreath,  Geo.  D.  Eveiington,  J.  T.  Moore, 
S.  T.  Flippin,  I.  H.  Foust,  O.  P.  Schaub,  John  B.  Ray,  W.  P. 
Knight,  Martin  McNeill,  Benjamin  Palmer,  J.  P.  Thompson, 
Charles  Highsmith,  J.  W.  McPherson,  R.  J.  Price,  Thad.  S. 
Troy,  E.  C.  Boyte,  A.  S.  Pendleton,  S.  F.  Pfohl,  O.  L.  Hollar, 
C.  H.  Bynum,  E.  H.  Spain hower,  W.  H.  Graves,  Alonzo  D. 
Lord,  J.  R.  Mask,  S.  B.  Woody,  C.  B.  Stephenson,  F.  L.  Dar- 
bonnier,  Charles  VanBergen,  E.  Moore,  Eugene  D.  Denson,  C. 
C.  Whitley,  A.  S.  McMillan,  W.  H.  Brooks,  Plato  H.  Lee, 
James  R.  Parker,  J.  VV.  Young,  S.  A.  Malloy. 

Of  this  numbers.  Dr.  W.  H.  Brooks,  of  Greensboro,  made  the 
highest  general  average  — 973^— with  one  exception,  the  highest 
mark  ever  received  by  a  candidate. 

Drs.  A.  S.  Pendleton,  of  Roanoke  Rapids,  and  Plato  H.  Lee, 
of  Alexandria,  each  made  93. 

Dr.  Jewett  moved   that  the  licentiates  reported    favorably  by 


--2  SOCIETY  REPORTS. 

the  Committee  on  Credentials  be  allowed  to  join  the  Society, 
pay  the  $5  initiation  fee,  which  was  to  be  immediately  refunded 
to  them.      Carried. 

The  following  resolution  was  offered: 

Resolved^  That  the  thanks  of  this  Society  are  due  and  are 
hereby  tendered  to  Drs.  Jewett  and  Perry,  Secretary  and  Treas- 
urer, for  the  efficient  manner  in  which  they  have  performed  the 
duties  pertaining  to  their  respective  offices. 

The  Nominating  Committee  made  the  following  report,  which 
was  adopted : 

Orator— Dr.  H.  S.  Lott. 

Essayist — Dr.  C.  L.  Minor. 

Leader  of  Debate — Dr.  J.  P.  Munroe. 

Board  of  Censors— Drs.  W.  O.  McDowell,  H.  H.  Harris  and 
J.  H.  Tucker. 

Publication  Committee — Drs.  R.  J.  Brevard,  J.  C.  Mont- 
gomery, R.  D.  Jewett  and  H.  T.  Bahnson. 

Legislative  Committee — Drs.  R.  H.  Lewis,  G.  T.  Sikes,  Abner 
Alexander,  James  McKee,  H.  A.  Royster. 

Obituary  Committee — Drs.  G.  \V.  Long,  J.  A.  Reagan,  K. 
P.  Battle. 

Delegates  to  American  Public  Health  Association — Drs.  W. 
J.  Lumsden,  Charles  Duffy,  J.  A.  Burroughs. 

Delegates  to  North  Carolina  Pharmaceutical  Association — 
Drs.  J.  W.  McGee,  Jr.,  J.  R.  Wheless,  J.  M.  Flippin. 

Delegates  American  Medical  Association — Drs.  W.  T.  Cheat- 
ham, Charles  J.  O'Hagan,  Charles  Duffy,  Willis  Alston,  J.  W. 
Long,  H.  T.  Bahnson,  E.  C.  Register,  J.  M.  Baker. 

Delegates  to  South  Carolina  Medical  Association — Drs.  I.  W. 
Faison,  G.  H.  Moran,  W.  T.  Pate. 

Delegates  to  Virginia  Medical  Society — Drs.  J.  C.  Walton, 
W.  A.  Graham,  A.  G.  Carr,  S.  L.  Montgomery,  W.  H.  H.  Cobb. 

The  following  communication  from  Dr.  Anna  M.  Gove  was 
received: 

Robert  D.  Jewett,  M.  D.,  Seeretary  Medical  Society 
of  the  State  of  North  Carolina. 
Permit  me  to  express  through  you  my  appreciation  of  the 
honor  conferred  upon  me  by  the  Medical  Society  of  the  State  of 
North  Carolina,  in  appointing  me  delegate  to  the  XH  Internat- 
ional Congress  of  Medicine.  My  only  regret  is  that  my  creden- 
tials from  this  body  did  not  reach  me  in  time  to   be  presented; 


SOCIETY  REPORTS. 

333 
in  fact,  I  received  them,  after  many  forwarding;,,  some  two 
months  after  my  return  to  North  Carolina. 

Much  forethought  on  the  part  of  the  Russian  committee  served 
to  make  traveling  easy  for  those  of  us  unacquainted  with  the 
language  and  customs  of  the  country.  On  the  border,  physi- 
cians or  medical  students  met  the  trains,  acted  as  interpreters— 
for  nearly  all  educated  Russians  speak  at  least  two  languages 
besides  their  own— helped  about  tickets,  passports,  customsin- 
spection,  and  registration  of  baggage.  At  the  Moscow  station, 
a  bureau  of  lodgings  undertook  to  provide  for  those  who  had 
not  already  secured  rooms,  and  delegates  wearing  the  XII  Con- 
gress badge  directed  us  to  the  bureau  where  membership  tickets 
were  issued.  The  Manege,  right  in  the  shadow  of  the  Kremlin 
served  as  general  headquarters.  Here  were  temporarily  located 
a  branch  post  office,  banking  department,  and  a  restaurant  for 
the  special  convenience  of  members. 

General  assemblies  occurred  in  the  Imperial  Theater.  Special 
sections  were  held  in  various  buildings,  as  a  rule  within  easy 
walking  distance  ot  the  bureau.  The  opening  Assembly  was  a 
most  impressive  spectacle,  but  here,  as  in  many  of  the  large 
sections,  it  was  almost  impossible  to  understand^  the  speakers, 
which  did  not  surprise  me  until  English  was  spoken,  when  I 
discovered  that  it  was  not  the  language  but  the  delivery  which 
was  at  fault.  As  a  rule,  the  European  delegates  were  men  of 
more  maturity  than  our  American  representatives.  Dr.  Senn, 
of  Chicago,  gave  at  the  second  general  assembly  a  paper- 
on  The  Classification  and  Surgical  Treatment  of  Acute  Peri- 
tonitis. Dr.  Senn  is  a  man  of  presence,  is  well  known  abroad, 
and  commanded  the  attention  of  a  fairly  good  audience,  which 
was  a  source  of  satisfaction  to  the  Americans  present,  as  there 
had  been  so  much  criticism  of  Dr.  Osier's  sending  a  substitute, 
Dr.  Thayer,  of  Baltimore,  an  undoubtedly  brilliant  man,  but 
one  much  better  known  at  home  than  abroad,  and  who,  from 
his  very  lack  of  years,  failed  to  command  the  attention  we  could 
have  wished  accorded  to  one  of  our  delegates.  At  the  section 
of  Internal  Medicine,  Dr.  Thayer  gave  a  paper  on  The  Increase 
of  Eosinophilic  Cells  in  Trichinosis,  and  also  a  communication 
on  Malrria,  which  was  illustrated  by  many  charts  and  very  in- 
teresting. 

On  the  outskirts  of  Moscow,  forming  a  little  village  by  itself, 
a  group  or  separate  buildings,  well  planned  and  equipped,  offer 
an  extensive  and  almost  ideal  arrangement  for  a  series  of  clinics. 
The  Foundling  Asylum,  with  sixteen  thousand  children  re- 
ceived every  year,  is  probably  better  known  to  foreigners  than  any 
other  institution  in  Moscow.  Here  babies  are  received,  rem  lin 
in  care  of  a  wet  nurse  for  two  weeks,  and  are  then  tiansferred 
to  country  homes.  Many  of  these  children  are  born  in  the  Mater- 
nity near  by,  where   they  average   six   thousand    deliveries   per 


334 


SOCIETY  RISPOKTS. 


year.  The  Maternity  is  clean  enough,  but  over  crowded,  and 
septic  patients  are  left  entirely  too  near  the  delivery  rooms;  ye«: 
I  believe  that  the  statistics — which  I  unfortunately  have  not  now 
at  hand — show  pretty  goad  results. 

The  social  part  of  our  entertainment  was  also  well  provided 
for  by  the  committee.  Receptions  and  concerts  were  arranged 
for  evenings,  and  we  left  feeiing  that  our  Russian  friends  had 
been  most  cordial  and  hospitable  in  every  particular. 

Again  extending  my  thanks  to  the  Society,  and  to  you  its 
Secretary^  for  the  courtesy  shown  me,  I  beg  to  subscribe  myself. 

Very  sincerely, 

Anna  M.   Gove. 

On  m-otion  the  session  was  then  adjourned. 


SECOND  DAY— EVENING  SESSION. 

The  Society  was  called  to  order  by  the  President  at  8:30 
o'clock. 

The  Annual  Oration  was  delivered  by  Dr.  Albert  Anderson,, 
of  Wilson,  on  "Two  Southern  Pioneer  Heroes  in  Surgery  and 
Gynecology." 

The  Annual  Essay  on  "The  Under  Side  of  Things  in  a  Doctors 
Life"  was  delivered  by  Dr.  Hubert  A.  Royster,  of  Raleigh. 

On  motion  of  Dr.  Bahnson,  the  Essay  and  the  Oration  were 
referred  to  the  Committee  on  Publication,  with  thanks  of  the 
Society, 

The  Finance  Committee  made  the  following  report,  which 
was  received  and  adopted: 

Your  Committee  on  Finance,  having  examined  the  books  and 

accounts  of  the  Treasurer,  beg  leave  to  report  the  following: 

To  balance  on  hand  June  8,  1897 $296.35 

Amount  collected  since 574.96 


Total.... $871.31 

By  amount  paid  Dr.  R.  H.  Lewis 2.10 

•'       Treasurer 100.00 

Secretary 125.00 

Carolina  Publishing  Co 17.00 

Stenographer 49.00 

W.  G.  Edgerton 4.77 

For  stamps 2.00 

Charlotte  Obsei'ver 2.50 

For  printing  Transactions 345.00 

Dr.  .Jewett 85.50. 

Dr.  Duflfy,  being  prize  money  left 

in  Treasury 50.00 

$782.92 


Balance  on  hand  May  3,  1898 $  75.09 


SOCIETY  REPORTS.  ^.^ 

We  recommend  the  usual  assessment  of  $2.00  per  capita,  that 
the  salary  of  the  Secretary  be$i25.oc  and  that  of  the  Treasurer 
be  $100,00  for  the  ensuing  year. 

In  view  of  the  depleted  condition  of  the  treasury,  the  Society 
cannot  undertake  to  pay  the  traveling  expenses  of  the  above 
named  officers.    •  C.  M,  Poole, 

Albert  Anderson, 
R.  L.  Gibbon, 

Committee  on  Finance. 


THIRD  DAY— MORNING  SESSION. 

The  Society  was  called  to  order  by  the  President. 

On  motion  the  time  of  next  meeting  was  left  to  the  Committee 
on  Arrangements. 

Dr.  J.  Howell  Way  presented  a  paper,  entitled  "Expert  Medi- 
cal Witnesses:  What  is  the  Cause  of  the'seeming  Disrepute  in 
which  their  Testimony  is  held  in  Certain  Recent  Cases  in  the 
Courts? — Observations  from  the  Standpoint  of  a  Country  Doc- 
tor."    Discussed  by  Dr.  Murphy. 

Dr  StClair  Davidson  read  a  paper  on  "Exsection  of  the  Gall 
Bladder  for  Impacted  Gall  Sone,"  which  was  referred  to  the 
Committee  on  Publication. 

Dr.  Poole  offered  the  following  resolution,  which  was  adopted. 

Resolved^  That  the  Committee  on  Publication  be  instructed 
to  have  the  transactions  of  this  meeting  bound  in  cloth,  pro- 
vided it  can  be  done  for  a  price  not  exceeding  50  cents  a  copy. 

Di.  Way  announced  that  the  Board  of  Medical  Examiners  had 
that  morning  received  the  resignation  of  Dr.  Burbank,  and  ac- 
cording to  the  rules,  they  proceeded  to  elect  in  his  place  Dr.  W. 
H.  H.  Cobb,  of  Goldsboro. 

Dr.  J.  P.  Munroe  offered  the  following  amendment  to  the 
Constitution  : 

Resolved,  That  Article  III.,  Section  2,  beamended  by  adding 
to  it  the  following:  But  any  licentiate  who  shall  apply  for 
membership  in  this  society  at  the  current  meeting  during  which 
he  has  been  licensed  by  the  Board  of  Examiners,  and  be  recom- 
mended by  the  Committee  on  Credentials,  shall  be  admitted 
without  paying  the  initiation  fee  of  five  dollars. 

According  to  the  Constitution,  it  was  left  over  till  next  meet- 
ing. 


236  SOCIKTYllEPORTS. 

The  Society  then  voted  on  the  report  of  the  Committee  on 
President's  Address,  item  by  item. 

ist.  That  the  Board  of  Examiners  meet  earlier,  in  order  that 
the  successful  candidates  may  have  an  opportunity  of  joining 
the  Society.  An  amendment  to  this  was  adopted  that  the 
Society  approves  the  action  of  the  Board  of  Ex-aminers  in  meet- 
ing at  an  earliei  day,  and  requests  the  Board  to  continue  this 
rule.  2nd,  That  those  licentiates  who  join  at  these  meetings 
shall  not  be  required  to  pay  the  initiation  tee  of  $5.  Adopted. 
3rd,  That  members  be  allowed  to  join  by  proxy,  being  recom- 
mended by  members  of  the  Society.      Not  adopted. 

The  papers  of  Drs.  D.  J.  Hill,  on  "Veratrum  Viride,  with  Es- 
pecial Reference  to  Its  Therapeutic  Uses  in  Serous  and  Paren- 
chymatous Inflammations,"  J.  M.  Parrott  on  "Remarks  on  the 
Country  Surgeon  and  His  Work,"  and  J.  G.  Blount,  "Chemis- 
try of  the  Stomach,"  were  read  by  title  and  referred  to  Com- 
mittee on  Publication. 

Dr.  Carr  offered  the  following  resolution: 

Resolved^  That  the  North  Carolina  Medical  Journal  be  no 
longer  considered  the  official  organ  of  the  North  Carolina  Medi- 
cal Society. 

A  motion  to  lay  the  resolution  on  the  table  was  unanimously 
adopted. 

The  following  resolution  was  offered  and  adopted. 

Resolved^  That  the  transactions  of  the  North  Carolina  Medical 
Society  be  no  longer  published  piece-meal  in  the  North  Carolina 
Medical  Journal  in  bi-monthly  issues,  but  published  as  a  whole 
within  60  days  after  the  meeting  of  said  Society,  or  as  soon 
thereafter  as  possible,  and  that  a  copy  be  furnished  each  member 
without  delay. 

The  Editor  of  the  Journal  asked  if  it  were  the  intention  of 
the  Society  that  the  papers  and  minutes  were  not  to  be  printed 
in  the  Journal,  whereupon  such  intention  was  denied. 

Un  motion,  the  Society  proceeded  to  the  installation  of  Offi- 
cers. Dr.  O'Hagan  and  Dr.  Murphy  were  appointed  to  escort 
the  newly  elected  President  to  the  Chair  Dr.  Francis  Duffy, 
the  retiring  President,  said:  Gentlemen,  in  vacating  this  chair 
to  my  worthy  successor,  I  desire  to  thank  you  again  for  the 
honor  conferred  upon  me  and  also  for  your  kindness  and  leni- 
ency towards  my  efforts  to  perform  perfectly  the  functions  of 
my  office. 


SOCIETY  REPORTS.  ».,- 

Dr.  O'Hagan  introduced  Dr.  Picot,  the  President- elect,  who 
said:  I  wish  to  thank  you  gentlemen,  for  this  evidence  of  kind- 
ness and  partiality  towards  me,  and  I  promise  you  to  do  my 
very  best  to  promote  the  future  interests  and  welfare  of  this 
Society.  I  can  only  hope  that  I  can  make  good  to  you  the 
promise  of  Dr.  O'Hagan. 

The  President  appointed  the  following  Chairmen  of  Sections: 

Pathology  and  Microscopy — Dr.  E.  B.  Glenn,  Asheville, 

Anatomy  and  Surgery — Dr.  Goode  Cheatham,  Henderson. 

Medical  Jurisprudence  and  State  Medicine — Dr.  Thos.  F. 
Costner,  Lincolnton. 

Obstetrics — Dr.  W.  W.  MeKenzie,  Salisbury. 

Gynecology — Dr.  W.  A.  Graham,  Charlotte. 

Practice  of  Medicine — Dr.  Benj.  K.  Hays,  Oxford. 

Materia  Medica  and  Therapeutics — Dr.  C.  S.  Mangum, 
Chapel  Hill. 

Chemistry  and  Physiology — Dr.  Josh  Taylor,   Washington. 

An  invitation  to  the  Society  from  the  Presbyterian  College  to 
a  reception  from  4  to  6  o'clock  was  read,  and  accepted  with  the 
thanks  of  the  Society. 

Also  one  from  Elizabeth  College,  to  visit  it  at  the  convenience 
of  the  Societv. 

The  following  names  were  favorably  reported  by  the  Com- 
mittee on  Credentials  and  recommended  for  membership: 

Drs.  G.  A.  Ramsaur,  T.  N.  Ried,  J.  R.  Alexander,  S.  J.  Love, 
J.  M.  Blair,  E.  M.  Brevard,  W.  M.  Fowlkes,  E.  R.  Russell,  G. 
S.  Tennent,  H.  N.  Abernathy,  Joy  Harris,  G.  A.  Brown,  C.  L. 
Minor,  S.  M.  Crowell,  J.  W.  P.  Smithwick,  S.  F.  Pfohl,  J.  A. 
WiUipms,  R.  C.  Ellis,  J.  D.  Williams,  L.  A.  Crewell,  G.  D. 
Everington,  C.  S.  Mangum,  F.  M.  Winchester,  J.  L.  Campbell, 
H.  D.  Stewart,  J.  R.  McClellan,  O.  P.  Schaub,  J.  W.  McPher- 
son,  J.  B.  Ray,  W.  P.  Knight,  J.  R.  Rierson,  S.  A.  Stearns,  S. 
T.  Fhppin,  J.  E.  S.  Davidson,  F.  H.  Gilreath,  W.  H.  Rogers, 
J.  I.  Campbell,  G.  A.  Katon,  W.  H.  Brooks,  E.  H.  Spainhower, 
J.  R.  Parker,  C.  M.  Strong,  W.  R.  McCain,  Chas. '  Highsmith, 
E.  B.  Glenn,  S.  E.  Ricks,  W.  E.  Hemphill,  C.  P.  Jones,  T.  E. 
McBrayer,  O.  C.  Champion,  W.  S.  Davidson,  R.  J.  Teague,  D. 
P.  Whitley,  W.  H.  Wooten,  John  Davidson. 

Drs.  W.  L.  Robinson,  of   Danville,    Va.,    Edmund    McGuire, 


^-3  ROY STER— ANNUAL  ESSAY. 

Hugh  L.  Taylor  and  Levy,  of  Richmond,  were  granted  the 
privilege'^  of  the  floor,  the  first  named  being  the  duly  accredited 
delegates  from  the  Virginia  Medical  Society. 

On  motion,  the  thanks  of  the  Society  were  extended  the  Char- 
lotte Medical  Society  and  the  citizens  of  Charlotte|for  their  gen- 
erous hospitality. 

The  Society  adjourned  to  meet  in  Asheville  sine  die. 
R.  D.  Jewett,  M.  D.,  Secretary, 

Winston,  N.  C.  Francis  Duffy,  M.  D.,  President, 

Newbern,  N,  C. 


ANNUAL  ESSAY. 
THE  UNDER  SIDE  OF  THINGS  IN  A  DOCTOR'S  LIFE. 

By  Hubert  A.  Royster,  A.B.,  M.D.,  Raleigh,  N.  C. 


INASMUCH  as  the  essayist  of  the  North  Carolina  Medical 
Society  is  privileged  to  address  a  general  audience,  it 
seems  fitting  to  select  a  subject  which  closely  concerns 
both  the  profession  and  the  laity.  One  of  my  friends  is  fond  of 
saying  that  nothing  is  interesting  unless  it  be  of  human  interest. 
The  brief  remarks  which  I  shall  make  this  evening  will  have 
much  to  do  with  folks  and  human  nature.  The  intention  will  be 
to  speak  simply  some  thoughts  which  constantly  push  themselves 
forward  in  the  mind  of  one  busied  with  daily  trials  in  the  practice 
of  medicine,  especially  as  these  thoughts  bear  on  the  personal 
relations  of  doctor  and  patient.  My  years  are  few  and  my  ex- 
perience is  small,  and  it  is,  therefore,  not  to  be  expected  that  this 
paper  will  contain  long  philosophical  deductions  founded  on  a 
broad,  matured  view  of  life  and  its  struggles.  Enough  has  come, 
however,  to  convince  me  that  too  little  is  known  by  the  physician 
and  his  patient  of  their  own  bearings  toward  each  other.  We 
seldom  stop  to  think  how  each  appears  ir  the  smaller  affairs  of 
our  existence. 

Why  do  folks    employ    physicians?     Most  people    send    for  a 
doctor  because  they  are  sick  or  think  they  are  sick.      That  seems 

*Read  at  45th  Annual  Meeting  of  the  North  Carolina  Medical  Society,  Char- 
lotte, May  3,  1898. 


ROYSTER-ANNUAL  ESSAY.  .- 

reasonable  enough.  There  are  some  who  must  have  a  doctor 
because  it  is  "the  thing"  to  do,  even  when  they  believe  a  physi- 
cian's services  are  not  needed.  Others  for  various  reasons  or 
excuses  refrain  from  sending  at  the  proper  time,  when  they  know 
ihey  should  do  so.  A  curious  phase  of  this  question  is  presented 
by  the  man  who  refuses  or  avoids  medical  counsel  because  he  is 
afraid  the  doctor  will  put  hina  to  bed,  cut  down  his  diet  or  tell 
him  to  stop  his  work  and  rest.  Now  the  man  himself  realizes  at 
once  that  he  ought  to  do  these  things:  if  not  why  should  he 
suppose  that  the  doctor  would  so  advise  him?  The  physician 
has  no  desire  to  control  a  man's  habits,  to  regulate  narrowly 
his  life  and  to  place  restrictions  upon  him.  He  would  gladly 
cure  his  patient  without  these.  It  it  is  the  doctor's  opinion  that 
the  sick  man  should  lie  in  bed  or  be  put  on  a  liquid  diet,  this 
seems  to  be  the  only  course  to  pursue.  It  is  the  only  one  pur- 
sued bv  those  who  have  made  up  their  minds  from  first  to  last 
to  do  right  regardless  of  their  own  feelings.  How  difficult  it  is 
for  us  all  to  sacrifice  our  personal  desires  for  what  our  conscience 
tells  us  is  the  absolute  right.  A  little  boy  once  said  this  was  a 
hard,  cruel  world,  because  every  thing  that  he  wanted  to  do 
was  wrong  and  every  thing  good  to  eat  was  unhealthy.  Are  we 
not  all  children  of  a  larger  growth?  But  these  people  of  whom 
we  have  been  speaking  are  those  who  cry  with  much  vehemence: 
"Oh!  yes,  always  do  what  your  doctor  tells  you  ;  what's  the  use 
of  having  a  doctor  and  paying  him  ,  if  you  don't  follow  his  di- 
rections?" The  only  use  in  their  cases  seems  to  be  to  do  just 
what  they  please  -to  carry  out  just  as  much  of  a  physicians 
orders  as  will  not  conflict  with  their  own  likes  or  dislikes.  By 
large  classes  of  people,  doctors  are  looked  upon  as  chronic  ob- 
jectors, who  go  about  seeking  to  find  something  which  they  can 
order  some  body  to  stop.  Let  me  say  emphatically  that  the 
doctor  is  not  an  autrocrat,  a  tyrant,  an  ogre-  not  even  an  exhorter 
or  a  pleader-  but  a  medical  adviser  in  the  passive  voice.  There 
should  be  no  getting  down  on  the  knees  and  begging  the  patient 
to  do  his  bidding.  The  man  is  a  free-will  agent ;  he  consults 
the  doctor;  a  certain  line  of  treatment  is  advised;  the  man  is  at 
liberty  to  carry  it  out  or  not  as  he  chooses.  The  resposibility 
of  the  medical  man  ends  with  the  advice  given.  Many  imagine 
it  is  to  please  the  physician  that  they  obey  his  orders,  that  they 


-  .^  ROYSTER— ANNUAL  ESSAY. 

34° 

confer  a  great  favor  on  him  every  time  they  take  a  dose  of 
medicine.  It  is  hard  to  make  them  see  that  the  treatment  is 
intended  to  do  good  to  them,  not  to  the  doctor.  Like  school 
children,  who  are  constantly  endeavoring  to  shirk  any  duty, 
they  fail  to  see  that  they  are  cheating  themselves,  not  the  teacher. 
Another  still  stranger  feature  is  seen  in  those  who  send  for  a 
doctor  in  whom  they  have  confidence,  buy  the  medicine  he 
prescribes,  and  that's  the  last  of  it.  The  ways  of  such  people 
are  like  the  ways  of  Providence — past  finding  out". 

It  is  the  physician's  duty  to  answer  all  calls  as  promptly  as 
possible.  Complaints  are  being  continually  hurled  atourheads 
for  not  getting  to  the  patient  as  soon  as  the  patient  himself  or 
the  friends  think  we  ought.  There  are  several  thing?  to  say 
about  this.  Emergency  calls  usually,  I  may  say  always,  receive 
immediate  attention.  In  the  ordinary  rounds  of  practice  it  is 
impossible  to  see  every  one  first;  the  doctor  cannot  be  in  several 
places  at  the  same  time.  He  must  use  his  own  judgment  as  to 
the  order  in  which  he  visits  the  sick.  Frequently  several 
persons  will  send  all  but  simultaneously,  each  asking  the  doctor 
to  stop  by  his  house  the  first  thing  as  he  starts  out.  Time  after 
time  messages  will  be  sent  telling  the  doctor  to  come  "at  once" 
when  on  questioning  at  the  time  or  on  arriving  at  the  house 
later  it  is  found  that  nr,  immediate  attention  was  needed  or  ex- 
pected by  the  patient.  Very  often  the  sick  one  will  be  in  the 
kitchen  or  sitting  up  chatting  with  friends  or,  possibly,  out  for 
a  little  stroll.  I  have  had  occasion  to  observe  in  my  own  practice 
each  of  these  circumstances.  After  such  people  cry  "wolf"  once 
or  twice,  the  doctor  learns  them  and  he  acts  accordingly.  Can 
you  blame  him?  With  some  in  my  own  practice,  a  hurry  call 
means  to  hurry  and  I  always  do  so.  I  know  they  need  a  doctor's 
services.  Others  make  day  and  night  hideous  with  false  alarms, 
so  that  it  is  hard  to  distinguish  the  true  ring.  What  most 
of  folks,  sick  or  well,  need  to  learn  is  that  there  are  one  or  two 
more  people  in  the  world  besides  themselves,  for  love  of  self, 
more  than  the  love  of  money,  is  the  root  of  all  evil. 

People  universally  seem  to  be  in  the  dark  concerning  the  real 
relations  of  physicians  to  one  another.  "You  doctors  are  so 
awfully  formal  in  your  ways"  and"  your  etiquette  is  very  peculiar" 
are  expressons  very  frequently'heard.  Etiquette  among  physi- 
cians is    founded  upon    ethics,  or  the  art    of   doing   right,    and, 


ROYSTER-ANNUAL  ESSAY 

defined  as  such,    the  way  is    perfectly  plain.      There  will    rarely 
be  any  friction  between    two  doctors   who  are  both    gentlemen 
A  gentleman  wants  to  do  right.      He  may  not  always  do  if  bui 
he  always  wants  to  do  right.      Among  the  members  of  the  medical 
profession  every  where  there  are  some  men  who   are  not   gentle- 
men, even    though,  in    many  cases,their  outward  conduct    may 
be  apparently  straightforward.    They  are  not  gentlemen  at  heart. 
Aud  their  professional  brethren  know  it  most  of  all.      Personally 
I  would  rather  one  of  my  respected  fellow-workers    should  con- 
sider me  capable  than  that  whole  cities  full  of  people  should  rise 
up  and  called  me  blessed.      It  is  a  fact,  I  think,  that  the  layman 
IS  scarcely  capable  of  judging  a  physician  upon  his  merits.      The 
majority  of  people  employ  a  certain  doctor  because  of  his  general 
reputation  gained    through  outward    impressions  on  themselves 
or  on  their    friends  and    associates.      They  continue  to    employ 
him,  granting    that  he   has    average  ability,  if  he  is    personally 
agreeable  to  them,  not,  as  a  rule,   on  account  of  any  particular 
skill  he  may  possess.      There  is  a  very  general  impression  among 
the    laity  that    for  most   ailments    any  physician  will    do;    that 
because  a  man  is  a  doctor  he   must    know  and  do  the  same  that 
all  other  doctors    know  and    do.      Studying    medicine   of    itself 
does  not  endow  a  man  with  a  better  or  bigger  brain  nor  does  it 
supply  him  with  reasoning  power  not  already  his  own.      It  only 
gives  him  some  more    facts,  tools  of   the    mind  and  skill  to    use 
them,    all  in  his    own    measure.      Mental  grasp,    judgment,  the 
ability  to  draw  correct  conclusions,  these  are  all  individual  attri- 
butes, obtained   by  inheritance   and   developed   by  general   ed- 
ucation.     No  one  could  really  expect  a  physician  to  reason  more 
logically  on  matters  in  medicine  than  about  those  of  every  day 
experience.      This  inability  of  the  layman  to   correctly  criticise 
the  doctor  is  the  cause  of  the  success  of  many  in  the  profession 
who  are   unworthy  to    be  in    it  and  who    become   notorious    by 
playing  to  the  public. 

The  doctor  has  most  abundant  opportunities  for  studying 
human  nature,  that  weak  thing  in  us  all,  with  which  we  excuse  a 
multitude  of  sins.  Did  you  ever  think  hjw  mean  human  nature 
really  is?  We  express  it  in  a  measure  when  we  attempt  to 
forgive  every  thing  low  and  vile  in  ourselves  by  saying  "well, 
we  can't  help  it;  it's  human  nature."     I  believe  it  wasDr.Deems 


-•2  ROYSTER- ANNUAL   ESSAY. 

who  said  that  there  was  "  lots  of  human  nature  in  folks  as  well 
as  in  hogs."  The  human  nature  in  folks  is  of  vital  importance 
to  the  physician.  He  comes  into  closer  relations  with  the 
people  in  a  community  than  do  either  ministers  or  lawyers.  A 
man  whom  the  church  and  the  law  regard  at  immaculate  may 
be  known  to  the  physician  as  a  profligate  in  his  inner  lite  and 
a  scoundrel  at  heart.  The  doctor  ci  rries  with  him  the  secrets 
of  life  "even  to  the  third  and  fourth  generations."  A  trained 
eye  and  careful  physicial  examination  sometimes  tell  the  medical 
man  all  he  wishes  to  know.  This  is  fortunate  for  there  is  nothing 
that  the  average  person  delights  in  more  than  to  keep  something 
from  his  doctor — a  trait  none  but  physicians  (and  observant  ones) 
realize  in  its  full  import.  It  would  be  astonishing  to  the 
people  in  this  audience  if  they  could  appreciate  how  often  a 
man  will  sit  in  a  doctor's  office,  where  he  has  come  to  obtain  re- 
lief, and  lead  the  doctor  off  the  track  by  telling  deliberate 
falsehoods,  and  the  pati-ent  would  be  equally  astonished  to  learn 
in  many  cases  that  the  doctor  knows  he  is  lying.  Such  things 
as  this  are  of  daily  occurrence  with  busy  and  watchful  physi- 
cians. Most  men  are  naturally  liars;  some  could  not  speak  the 
truth,  if  they  tried;  very  many  do  not  even  try.  It  has  been 
said  that  if  you  run  out  in  the  street  any  where  and  grab  the 
first  man  you  meet,  nine  times  out  of  ten  you  have  a  liar.  But 
I  was  saying  that  doctors  get  very  close  to  the  people.  They 
go  into  the  home,  into  the  family  and  learn  every  member  of  it, 
both  in  sickness  and  in  health;  for  they  study  all  the  others 
while  in  attendance  on  the  sick  one.  The  remark  is  so  often 
made  that  the  doctor  sees  the  sick  man  at  his  worst,  on  his  back, 
suffering;  and  that  therefore,  he  should  excuse  the  man  for  all 
sorts  ot  weaknesses  and  meanness,  on  the  ground  that  the  man 
is  not  himself.  I  claim  that  the  patient  unless  he  be  delirous  or 
comatose,  is  very  much  more  himself,  with  his  shell  off,  with 
his  society  manners  laid  aside  and  his  true  disposition  revealed. 
His  moral  nature  can  then  be  observed  in  its  primitive  state. 
We  can  find  out  whether  he  is  considerate  of  others,,  whether 
he  is  courageous  in  the  presence  of  pain,  whether  he  warts  to 
do  right.  True  illness  of  any  kind  is  apt  to  make  one  disa- 
greeable, but  it  does  not  add  anything  new — only  brings  out  the 
old.      The  moral   nature  in   folks  is  indeed   an  interesting  and 


EOYSTER-ANNUAL  ESSAY.  «    „ 

profitable  study  for  physicians.  By  this  I  do  not  mean  the 
attribute  in  men  which  makes  them  religious,  but  the  innate 
principle,  the  motive  for  doing  things,  good  or  bad.  The 
study  of  nervous  degeneracy  and  its  hereditary  influence  is 
productive  of  valuable  results.  The  lack  of  moral  sense  is  often 
mistaken  for  feeble  intellectual  development.  There  are  oc- 
casions when  a  doctor  finds  difficulty  in  having  his  directions 
carried  out  even  after  he  has  gone  togreat  lenghts  in  explaining 
them  to  some  member  of  a  family.  The  trouble  is  supposed  to 
result  from  a  want  of  understanding  and  at  times,  it  may;  but 
often  it  is  due  to  the  fact  that  the  person  to  whom  the  orders 
are  given  is  absolutely  devoid  of  a  sense  of  moral  obligation  and 
is  arrayed  on  the  opposite  side  always.  Such  a  person  never 
determined  to  do  right  about  anything.  Anyone  can  compre- 
hend a  few  directions  simply  stated,  but  it  takes  a  person  of 
strong  moral  nature  to  want  to  follow  them  implicitly. 

It  is  wonderful  how  people  neglect  to  take  a  doctor's  advice, 
to  what  ends  they  will  go  to  deceive  him  and  then  how  ready 
ihey  are  to  blame  the  doctor  if  anythtig  goes  wrong.  I  will 
acknowledge  that  most  people  do  not  cast  the  blame  on  their 
doctor  unjustly.  But  many  do  and  generally  for  the  most 
trifling  reasons  and  without  cause.  Just  as  a  physician  com- 
monly makes  his  reputation  by  the  smallest  things,  so  in  the 
same  way  he  often  mars  or  loses  it.  The  conscientious  medical 
man  throughout  all  ages  and  countries  has  silently  steeled 
himself  against  this  and  has  plodded  along. 

'•Knowing  if  he  won  the  battle  they  would  praise  his  Maker's  name; 
Knowing  if  he  lost  the  battle  then  the  doctor  was  to  blame." 

This  verse  would  serve  as  the  text  for  a  more  elaborate  effort 
than  I  feel  able  to  undertake  but  it  suffices  to  show  one  other 
phase  in  human  nature.  The  gratitude  of  patients  is  worth 
much  to  physicians,  more  sometimes  than  any  price  which  could 
be  paid.  How  many  times,  when  a  man  is  flat  of  his  back, 
would  he  offer  his  whole  fortune  to  get  well  and  when  on  his 
feet  give  nothing  to  the  doctor  in  return  save,  perhaps,  abuse 
for  keeping  him  down  so  long;  or  promise  filty  dollars  before 
an  operation  and  not  even  render  thanks  afterwards: 

"When  the  devil  was  sick,  the  devil  a  saint  would  be: 
When  the  devil  got  well,  the  Devil  a  saint  was  he." 


^^.  ROYSTER- ANNUAL  ESSAY, 

Alas!  how  often  it  is  that  "gratitude  is  a  lively  expectation  of 
more  favors  to  come."  In  the  experience  of  nearly  all  doctors 
among  ungrateful  patients  are  those  who  receive  the  largest 
amount  of  charity  work.  The  man  who  gets  the  attention  and 
pays  his  money  for  it,  feels  that  he  has  received  full  value  and 
is  accordingly  grateful.  It  has  been  said  that  if  you  wish  to 
make  an  enemy  of  a  man,  do  him  a  personal  favor  or  lend  him 
money. 

Turning  away  from  this  baser  side  it  is  refreshing  to  know 
that  there  are  higher  and  better  things  in  a  doctor's  life.  To 
feel  that  we  have  been  instrumental  in  saving  the  life  of  even 
one  human  being,  be  he  grateful  or  ungrateful,  scoundrel  or 
gentleman,  is  a  noble  and  satisfactory  reflection.  Nothing  can 
take  from  us  the  consolation  arising  from  a  knowledge  of  duty 
well  performed,  suffering  relieved,  death  averted.  And  yet  the 
moral  attitude  of  his  patient  must  always  have  its  influence  on 
the  physician,  who  is  also  human.  A  doctor  would  prefer  a 
whipping  to  entering  the  doors  of  some  homes  ;  there  are  others 
in  which  the  hard  work  he  does  is  never  irksome.  The  difference 
lies  wholly  in  the  moral  sense  of  the  people  themselves.  It  is 
natural  to  separate  the  chaff  from  the  wheat ;  to  cast  some  people 
entirely  out  of  our  lives,  while  we  grapple  others  to  us  with  hooks 
of  steel.  A  great  part  of  a  doctor's  success  lies  in  his  ability  to 
understand  folks,  their  goodness  and  their  meanness — to  weigh 
their  moral  natures  in  the  balance  of  cold  logic.  One  of  the 
most  important  points  in  any  diagnosis  is  to  find  out  whether 
the  patient  is  lying  or  not.  If  he  is,  discard  the  history  and 
depend  on  your  physical  examination  ;  if  he  is  not,  shake  hands 
with  him,  but  consider  carefully  what  he  says. 

As  this  article  is  being  rounded  to  a  close  I  am  reminded  that 
it  savors  extremely  of  t  he  pessimistic.  And  yet  the  picture  is 
not  so  black  but  that  the  light  may  be  seen  shining  from  behind 
the  dark  background.  We  cannot  appreciate  the  good  without 
knowing  the  bad.  Nor  can  we  do  right  unless  we  know  what 
wrong  is.  I  have  brought  before  you  here  glimpses  of  the  inner 
life  of  physicians  (for  we  all  have  about  the  same  sort  of  experi- 
ences) and    the    personality  of  their    patients.      In  doing  this    I 


BROWNSON--THE  TOBACCO  HABIT  AS   A  CAUSE  OF  DISEASE 

345 
have  necessarily  spoken  of  some  evil,  but  with  the  hope  that 
good  may  come.  Doctors  must  not  shut  their  eyes  to  the  seamy 
side  of  nature  but  must  study  both  the  good  and  the  bad  in  the 
characters  of  their  patients.  Nor  will  it  profit  to  look  upon 
every  patient  as  a  "case"  forgetting  the  finer,  deeper  elements 
within  each  individual.  There  is  too  great  a  tendency  toward 
this  in  these  later  days  and  it  may  not  be  amiss  to  say  seriously 
in  the  language  of  another,  that  the  human  stomach  is  not  a 
test  tube  and  the  body  is  not  a  laboratory. 
323  W.  Morgan  Street. 


THE  TOBACCO  HABIT  AS  A  CAUSE  OF  DISEASE. 
By  W.  C.  Brownson,  M.D.,  Asheville,  N.  C. 


1WISH   to  p'-eface  my  remarks  by  stating  that  I  am  in  no  de- 
gree afflicted  with  tobacco  phobia. 

I  do  not  believe  with  Meta  Landers,  whose  hysterical  de- 
nunciations of  tobacco  may  be  familiar  to  you,  that  the  tobacco 
user  is  a  vile  creature,  or  that  he  must  inevitably  suffer  in  his 
mental  and  physical  being  from  his  indulgence  of  the  habit. 
Many  persons  derive  much  pleasure  from  the  moderate  use  of 
tobacco  and  no  possible  harm,  but  many  are  less  fortunate  and 
are  injured  by  it.  Let  us  consider  for  a  few  moments  some  of 
the  most  common  manifestations  of  its  evil  effects. 

The  symptoms  presented  in  acute  poisoning  by  tobacco  are 
known  to  every  one.  The  pale,  sweat-bedewed  face,  the  deathly 
faintness,  the  complete  muscular  relaxation,  the  feeble,  flutter- 
iag  pulse  shown  by  the  beginner  after  his  first  cigar  or  initial 
"chew,"  prove  that  tobacco  is  a  most  virulent  poison  ;  it  is  also 
a  local  irritant. 

Nicotine,  the  active  principle  of  tobacco,  is,  it  is  probable, 
responsible  almost  entirely  for  the  deleterious  influence  of  the 
plant,  but  it  eontains,  in  addition,  various  salts  and  an  empyc- 
reumatic  oil,  the  latter  by  chemical  processes  yielding  numerous 
alkaloids  scarcely  less  poisonous  than  nicotine  itself. 

Tobacco,  it  seems  from   experimentation,  has  no    perceptible 


,  ,5         BROWNSON— THE  TOBACCO  HABIT  AS  A  CAUSE  OF  DISEASE. 

effect  on  the  brain;  its  depressing  action  is  exerted  on  the  spinal 
cord  and  the  sympathetic  nervous  system.  Upon  the  heart  it  is 
said  to  have  no  direct,  effect,  though  by  its  depressing  influence 
on  the  pneumogastric  and  the  vasomotor  system,  the  heart  is 
powerfully  influenced. 

The  effects  of  the  tobacco  habit  may  be  divided  into  its  con- 
stitutional or  general,  and  its  local  or  irritant  results.  As  to 
the  general  systemic  disturbances,  the  various  modes  of  using 
tobacco,  smoking,  chewing,  snuffing  and  dipping,  have  much 
the  same  action  ;  though  there  are  without  doubt  individual 
idiosyncrasies,  on  account  of  which  in  the  one  case,  smoking,  in 
the  other,  chewing,  may  be  better  borne  by  the  system,  but  the 
larger  the  amount  of  tobacco  consumed,  the  greater  the  amount 
of  nicotine  absorbed  into  the  system,  the  greater  the  consti- 
tutional disturbances. 

As  with  other  narcotic  poisons,  tolerance  varies  widely  in  dif- 
ferent individuals.  No  special  number  of  cigars  or  pipes  per 
day  can  be  prescribed  as  being  within  the  danger  line.  What  is 
moderation  for  one  person  would  be  excess  for  another.  Those 
of  lymphatic  temperament,  large  feeders  with  a  good  digestion, 
can,  as  a  rnle,  use  an  amount  of  tobacco  without  apparent 
injury  that  would  be  ruinous  to  one  of  spare  build,  nervous 
temperament  and  poor  stomach. 

Age  is  a  most  important  factor  in  the  results  of  the  tobacco 
habit.  In  the  young,  growing  boy,  tobacco  causes  its  most 
serious  effects,  and  chorea,  epilepsy  and  insanity  have  resulted 
from  its  excessive  use. 

The  vaiious  forms  of  dyspepsia,  faulty  digestion,  both  gastric 
and  intestinal,  are  the  most  frequent  evidences  of  the  baneful 
influence  of  tobacco.  In  part,  they  result  from  altered  or  defi- 
cient salivary  secretion;  in  part,  from  the  depressing  effects  of 
nicotine  on  the  nervous  system.  If  tobacco  is  given  up,  again 
in  weight  almost  invariably  follows.  The  functional  diseases 
of  the  heart,  characterized  by  its  rapid,  irregular  or  fluttering 
action,  are  very  frequently  caused  by  the  abuse  of  tobacco  as 
all  observers  agree.  These  functional  disorders  may  lead  to  or- 
ganic disease,  to  dilatation,  hypertrophy  and,  perhaps,  valvular 
changes.  General  arterio-sclerosis  and  angina  pectoris  are  by 
some  authorities  said  to  be  due  to  immoderate  indulgence  in  to- 


BROWNSON-THE  TOBACCO  HABIT  ASA  CAUSE  OF  DISEASE  ,  ,  - 

347 

bacco.  The  manner  in  which  these  changes  are  brought  about  is 
(not  well  understood,  but,  as  is  said  by  Page  in  his  Physical 
Diagnosis,  "It  is  so  all  the  same."  Tobacco,  it  would  seem, 
has  no  direct  effects  upon  the  heart,  as  after  painting  it  with  a 
concentrated  solution  of  nicotine,  the  heart  beats  on  apparently 
undisturbed.  Probably  "a  definent  action  of  the  Pneumogas- 
tric"  is  brought  about  by  the  poisonous  principle  of  tobacco 
"whereby  the  heart  is  not  properly  controlled,"  or  "  to  sudden 
vasomotor  relaxations  which  by  dilating  the  blood  paths  reduce 
the  normal  arterial  resistance." 

It  is  my  belief  that  tobacco  is  one  of  the  most  fruitful  causes 
of  neurasthenia,  and  it  was  a  surprise  to  find  in  looking  over 
Beard's  Classic  "Treatise  on  Nervous  Exhaustion"  recently, 
that  he  nowhere  mentions  tobacco  as  a  cause  of  the  disorder. 
Certainly,  very  many  of  the  symptoms  that  he  so  graphically 
describes,  —  "the  atonic  voice,"  "the  mental  irritability,"  the 
"morbid  fear"  in  its  various  divisions,  such  as  "anthiophobia, " 
(fear  of  man)  ;  "gynephobia,"  (fear  of  woman) ;  "pathophobia," 
(fear  of  disease)  etc.,  the  frequent  blushing,  profuse  sweating 
without  cause,  local  spasms  of  muscle  (tremor),  nervous  chills 
and  flushes  of  heat,  temporary  paralysis  etc., — all  these  are  met 
within  the  subjects  of  the  tobacco  habit.  It  is  hard  to  fix  the 
dividing  line.  It  is  a  question  often  whether  there  be  any  di- 
viding line  between  neurasthenia,  hysteria,  lithaemia,  and  we 
might  add  melancholia.  Certain  it  is  that  all  the  various  symp- 
toms and  manifestations  described  under  these  headings  in  our 
text  books,  are  met  within  those  who  use  tobacco  to  excess,  and 
that  they  are  caused  by  tobacco  is  evidenced  by  the  fact  that 
they  either  disappear  entirely  or  are  very  much  lessened  in  de- 
gree when  tobacco  is  discontinued.  All  of  the  symptoms  spoken 
of  under  neurasthenia  may  be  met  with  in  chronic  alcoholics 
and  also  in  those  who  are  given  to  sexual  excess.  Therefore,  it 
must  frequently  be  impossible  to  decide  which  vice  is  the  lead- 
ing agent  in  the  cause  of  these  disturbances,  but  we  will  fre- 
quently be  able  to  exclude  any  suspicion  of  alcoholic  indulgence 
or  of  sexual  indiscretions,  and  to  decide  positively  that  the  im- 
moderate consumption  of  tobacco  is  responsible  for  the  patient's 
condition;  but  to  convince  him  of  this  fact,  and  to  include  him 
to  forego  his  unfortunate  habit  is  often  an  impossible  task. 


,  ,  3        BROWNSON-THE  TOBACCO  HABIT  AS  A  CAUSE  OF  DISEASE. 

Among  the  various  toxic  substances  producing  amblyopia  or 
impairment  of  vision,  tobacco  is  known  to  ophthalmologists  to 
be  one  ot  the  chief.  The  poisoning  by  nicotine  occasions  a  retro- 
bulbar neuritis  which  may  result,  if  the  tobacco  habit  is  presis- 
ted  in,  in  almost  complete  loss  of  sight.  Tobacco  amblyopia  is 
known  to  result  most  frequently  in  heavy  smokers  of  the  pipe, 
who  consume  the  strongest  and  most  juicy  tobacco.  Many  a 
man  attributes  his  gradual  failure  of  vision  to  advancing  age, 
when  his  fondness  for  a  rank  and  ancient  pipe  is  alone  answerable 
for  his  condition.  When  the  cause  of  the  defective  sight  is 
recognized  and  the  tobacco  is  abandoned,  a  cure  usually  results. 

Certain  other  diseases,  notably  tabes  dorsalis  and  general 
paresis  have  been  charged  to  the  acount  of  tobacco,  but  there 
is  not  sufficient  evidence  it  would  seem  to  prove  a  causative  in- 
fluence. Enough  has  been  said  of  the  constitutional  effects  of 
tobacco.     A  few  words  now  as  to  its  local  action. 

The  irritative  effects  of  tobacco  upon  the  mucous  membranes 
are  almost  invariably  seen,  to  some  degree,  in  all  who  use  it 
largely,  in  all  great  smokers  certainly.  "Snuffing"  is  practic 
ally  obsolete  in  this  country  and  of  its  irritating  effect  on  the 
nasal  mucous  membrane,  we  cannot  judge  by  actual  observa- 
tion. 

The  habit  of  "dipping  snuff"  is  very  prevalent  among  women 
of  the  poorer  classes  in  some  portions  of  the  South,  and  its  evil 
results  are  manifold.  In  addition  to  the  constitutional  effects 
occasioned  by  this  habit,  shown  in  the  muddy  complexion,  the 
dyspepsia,  the  palpitation  of  the  heart  and  often  neurasthenia 
and  hysteria,  there  is  the  direct  irritant  action  upon  the 
gums;  this  is  increased  by  the  rubbing  to  which  they  are  sub- 
jected by  the  snuff  laden  "brush"  before  it  is  tucked  away  in 
the  cheek.  A  chronic  gingivitis  results,  the  gums  recede  from 
the  teeth,  the  teeth  drop  out  one  by  one,  giving  an  appearance 
of  premature  and  unlovely  age  to  what  should  be  a  fresh,  youth- 
ful, attractive  face. 

The  chewing  of  tobacco,  in  so  far  as  I  have  been  able  to  ob- 
serve, rarely  causes  local  symptoms.  The  constant  stimulation 
to  the  salivary  glands  occasioned  by  its  presence  in  the  mouth, 
has  apparently  no  injurious  effect  upon  these  over-worked  glands, 
and  the  mucous  membrane  of   the  mouth,    pharynx   and   naso- 


BRO"VVNS01Sr-TIIE  TOBACCO  HABIT  ASA  CAUSE  OF  DISEASE.         ,  .  „ 

349 
pharynx  is  apparentlj'-  no  more  prone  to  inflammation  in  the 
chewer  than  in  the  non-user  of  tobacco. 

Constitutional  symptoms  are  perhaps  more  frequently  induced 
by  chewing  than  by  smoking.  The  confirmed  tobacco  chewer  is 
rarely  ever  without  his  quid  and  is,  therefore,  more  constantly 
absorbing  nicotine  into  his  economy  than  the  smoker. 

Those  who  smoke  to  any  considerable  extent  almost  invariably 
present  evidences  of  local  irritation.  In  how  much  the  irrita- 
tion is  due  to  the  more  or  less  heated  smoke  as  smoke  and  in 
how  much  to  the  plant  giving  forth  the  smoke,  is  a  question.  It 
is  very  probable  that  the  smoke  from  any  dried  leaves  would 
have  an  equally  injurious  action  upon  mucous  membranes  as 
the  smoke  :;rising  from  burning  tobacco.  According  to  some 
authorities,  (notably  Bosworth),  the  catarrhal  inflammations 
found  in  the  smoker  are  not  due  to  irritation  bj'  the  smoke  but 
to  nicotine  poisoning.  However  this  may  be,  a  large  propor 
lion  of  all  smokers  have  constantly  a  furred  tongue,  most  marked 
in  the  morning,  and  a  bad  breath.  This  condition,  as  a  rule, 
does  not  indicate  any  special  derangement  of  digestion,  but  is 
due  to  a  chronic  superficial  glossitis.  Cigar  smokers  are  less 
prone  to  it  than  users  of  the  pipe,  and  tobacco  chewers  are 
nearly  exmpt  so  fa)'  as  my  observation  goes.  The  form  of  glos- 
sitis, commonly  known  as  "black  tongue,"  characterized  by 
great  elongation  of  the  filiform  papilla;  with  a  blackish  discolor- 
ation over  a  circumscribed  spot  of  varying  size,  may  sometimes 
be  caused  by  the  irritation  of  tobacco  smoke;  the  two  cases  I 
have  seen,  at  any  rate  were  found  in  confirmed  smokers. 

Chronic  pharyngitis  and  naso-pharyngeal  catarrh  are  very 
common  in  those  who  smoke  to  excess.  As  I  have  said,  Bos- 
worth asserts  that  these  cases  are  not  due  to  local  irritation 
from  the  smoke  but  tr.  the  absorption  of  nicotine  and  the  dis- 
ordered stomach  occasioned  by  it.  It  is  probably  true,  as  he 
savs,  that  the  smoke  does  not  reach  the  pharynx  at  all  in  ordi- 
nary cases.  Any  smoker  knows  from  occasional  experience 
with  a  green  cigar  or  a  very  acrid  tobacco,  that  the  point  of 
impact  of  the  burningsmoke  in  the  anterior  portion  of  the  mouth 
and  that  no  sensation  of  heat  is  felt  in  the  pharynx.  Beverly 
Robinson  says  nothing   in    his    work    of   tobacco  as   a  cause   of 


^^Q       BROWNSON-THE  TOBACCO  HABIT  AS  A  CAUSE  OF  DISEASE. 

naso-pharyngeal  catarrh;  neither  does  Morell  Mackenzie  men- 
tion it  as  an  etiological  factor.  Other  authorities,  however,  and 
I  may  instance  Dudley  Buck,  accuse  tobacco  smoking  of  caus 
ing  a  chronic  irritation  of  the  pharynx  and  resultant  disease  of 
the  middle  ear  from  extension  along  the  eustachian  tube.  He 
says  the  man  who  smokes  heavily  frequently  presents  a  pharynx 
strongly  resembling  that  of  a  scarlet  fever  pat-ent. 

The  hot  smoke  from  a  short  pipe  is  more  apt  to  inflame  the 
throat  than  is  the  cooler  smoke  of  a  cigar.  Some  men,  while 
using  the  pipe,  constantly  suffer  from  a  more  or  less  pronounced 
nasopharyngeal  catarrh,  which  they  are  never  troubled  with 
using  the  less  economical  cigar. 

Tobacco  smoking  has  been  said  to  cause  epithelioma  of  the 
tongue  and  lip.  Whether  it  does  so  is  a  mooted  point,  but  as 
any  prolonged  irritation  may  produce  a  malignat  growth  in  a 
subject  prone  to  the  development  of  neoplasms,  it  is  probable 
that  tobacco  is  at  least  an  occasional  cause  of  cancer. 

There  is  no  object  in  extending  the  list  of  disorders  occasioned 
by  the  tobacco  habit.  Enough  has  been  said  to  show  that  it  is 
a  frequent  cause  of  disease,  while  it  induces  many  more  or  less 
alarming  symptoms  that  may  lead  to  real  disease. 

Tobacco  is  a  potent  agent  for  harm.  It  should  never  be  used 
by  the  young,  growing  boy  or  by  the  thin,  nervous  dyspeptic. 
The  physician  should  always  point  out  its  dangers  when  he  sus- 
pects it  to  be  doing  harm,  and  insist  that  it  be  given  up  at  once. 


REPORT  OF  CHAIRMAN  OF  SECTION  ON  PRACTICE 
OF  MEDICINE. 

By  M.  H.  Fletcher,  M.  D.,   Asheville,  N.  C. 

AFTER  reviewing  carefully  during  the  past  year  a  part,   at 
least,  of  the  abundance  of  literature  which  has  been  prin- 
ted on  medical  subjects,  and  viewing  it  from   the  stand- 
point of  a  general  practitioner,  it  is   difficult   to  state  just   how 
much  progress  we  have  made.      That  which  concerns  us  most  is 
the  treatment  of  disease,  and  I  am  not  prepared  to  state  that  we 


FLETCHER-REPORT  ON  PRACTICE  OF  MEDICINE. 

can  better  or   more   unsuccesfully   treat  disease    now   than    we 
could  ten  years  ago. 

I  would  not  for  one  minute  intimate  that  medicine  is  not  a 
progressive  science.  Certainly  not  within  my  knowledge  have  the 
members  of  the  profession  been  so  thoroughly  aroused  as  to  the 
possibilities  aud  the  future  of  medicine  as  at  the  present  time, 
and  the  interes  manifested  is  notcofined  to  the  medical  centres. 
The  country  doctor  and  the  doctor  in  the  remote  districts  is 
alive  to  the  interests  of  his  profession.  When  we  see  thousands 
of  good  men  in  the  laboratories,  in  the  hospitals  and  in  private 
practice,  all  working  along  different  lines  and  arriving  at  the 
same  conclusion,  with  the  same  object  in  view,  i.  e.  :  the  study 
of  medicine  from  a  purely  scientific  standpaint,  good  must  re- 
sult from  it. 

The  greatest  advances  are  being  made  in  etiology,  pathology 
and  diagnosis,  and  however  much  we  dislike  to  have  our  pet 
theories  in  regard  to  certain  diseases  upset,  or  how  often  we 
are  driven  from  our  beliefs  when  nothing  better  is  offered  us, 
still,  medicine  is  each  year  getting  further  away  from  empiri- 
cisms, and  is  being  founded  on  a  scientific  basis.  When  we 
understand  fully  the  cause  and  know  thoroughly  the  pathology, 
symptoms  and  course  of  a  disease,  rational  treatment  must 
follow. 

The  increase  in  the  number  of  medical  colleges  in  the  country 
may,  in  a  measure,  be  responsible  for  an  overcrowded  profession 
and  a  number  of  other  ills  along  this  line,  but  at  the  same  time, 
they  are  a  stimulus  to  men  to  work  and  do  good  in  this  way. 

In  my  judgement,  one  of  the  greatest  dangers  to  the  progress 
of  treatment  of  disease  lies  in  the  encouragement  given  by  the 
profession  to  the  enterprising  drug  firms  and-  the  proprietary 
medicine  men  of  the  country.  We  often  prescribe  these  remedies, 
the  especial  value  of  which  consists  in  the  way  in  which  they 
are  prepared, — a  knowledge  of  which  process  we  are  entirely 
ignorant.  'Tis  true,  most  of  them  bear  a  formula  but  I  venture  to 
assert  that  in  nine  cases  out  of  ten  when  we  prescribe  these  nos- 
trums, we  cannot  tell  just  what  size  dose  of  each  drug  we  are 
giving,  or  the  effect  each  one  is  expected  to  produce.  While  the 
formula   comes   with    the  remedy,    no  competent  druggist  can 


JC2  FLETCHER-REPORT  ON  PRACTICE  OP  IVIEDIOINE. 

make  a  similar  product  from  the  same  combination.  These  en- 
terprising drug  firms,  who  have  no  interest  in  medicine  except 
the  com.mercial  side  of  it,  will  try  to  monopolize  everything 
that  is  new,  and  resort  to  every  kind  of  method  of  advertising 
in  order  to  get  a  "Run"  on  worthless  remedies.  The  most  dis- 
couraging fact  in  this  connection  is  that  we  make  our  local 
druggist  who,  as  a  rule,  is  a  competent  and  an  educated  man, 
a  distributing  agent  for  the  nostrums;  while  the  enterprising 
manufacturer  grows  rich,  our  honest  local  druggist  starves  and 
his  knowledge  of  pharmacy  runs  to  seed.  The  agents  of  these 
firms  who  are  always  polite  and  agreeable  are  becoming  a  nui- 
sance; they  infest  our  offices  and  claim  a  share  of  our  time  when 
we  ought  to  be  otherwise  employed  ;  they  are  persistent  in  ex- 
acting a  promise  to  prescribe  this,  that  or  the  other  remedy,  in 
order  to  keep  it  from  falling  into  disuse. 

I  realize  that  our  local  druggist  cannot  always  be  a  manu- 
facturer ol  drugs,  but  he  ought  to  be  allowed  to  combine  the 
remedies  which  are  daily  in  use.  There  are  a  number  of  agents 
used  in  medicine,  such  as  vaccine  virus,  antitoxin  and  other 
serums  which  should  be  propagated  under  the  supervision  of 
our  government.  Useful  remedies  of  this  class  are  liable  to  be 
dropped  from  our  list  owing  to  the  fault  of  their  preparation. 

We  offer  as  proof  that  medicine  is  a  progressive  science, — 
books  written  ten  years  ago  are  now  out  of  date.  The  pathology 
and  the  practice  are  constantly  changing.  With  our  recent 
theories  in  regard  to  the  causation  of  disease  being  confirmed 
by  so  many  good  men,  the  pathology  and  then  the  treatment 
will  follow  and  rest  on  a  securer  basis.  There  are  still  a  num- 
ber of  questions  in  this  particular  which  are  yet  unsettled  in  the 
mind  of  the  general  practitioner. 

It  is  discouraging  to  note,  for  instance,  in  pneumonia,  while 
its  cause  is  better  understood  and  we  have  made  advances  in  its 
pathology  and  diagnosis,  no  distinct  advancement  has  been 
made  in  its  management  and  treatment;  the  death  rate  has  not 
been  diminished.  If  any  drug  exerted  a  specific  influence  in 
this  disease,  there  would  not  be  such  a  diversity  of  opinion  in 
regard  to  its  treatment.  No  two  practitioners  treat  the  disease 
alike, — one  will  advise  you  to  use  the  cold  pack,  another  a  warm 
poultice.      The  pathologists  tells  us  that  there  is  hope  of  prog- 


FLiETCHSR-RSPORT   ON   PRACTICE  OF  MEDICINE  ^^, 

ress  in  this  direction,  now  that  its  etiology  is  better  understood. 
We  are  taught  that  the  consolidations  which  occur  rapidly  in 
most  cases  are  not  in  their  nature  purely  inflammatory,  on  the 
contrary,  the  local  exudation  in  the  lungs  is  found  to  be  depen- 
dent upon  the  presence  of  septic  germs  as  a  specific  causative 
factor  and  the  combined  symptoms  rank  it  as  an  essential  fever. 
Our  country  laity  are  not  so  very  wrong  when  they  speak  of  it 
as  "pneumonia  fever."  Even  before  we  knew  that  pneumonia 
was  dependent  upon  the  presence  of  one  or  several  micro- 
organisms, we  were  positive  that  it  should  be  classed  among  the 
infectious  diseases  and  that  it  was  disseminated  by  contact.  I 
believe  that  we  can  often  prevent  pneumonia  by  treatinar  it  as  a 
communicable  disease.  In  the  future,  the  object  of  treatment 
will  be  rather  to  diminish  the  number  of  cases  and  protect  the 
community  in  this  way. 

The  usual  amount  of  discussion  has  occurred  during  the  year 
as  tD  the  best  method  of  treatment  of  Typhoid  Fever.  No  one 
-it  the  present  time  questions  that  Typhoid  Fever  is  due  to  a 
specific  germ  and  the  object  of  treatment  is  to  get  rid  of  these 
germs  and  their  v/eapons  the  toxins,  without  injury  to  the  pa- 
tient. Since  we  have  no  specific  remedy  to  meet  the  indication 
as  referred  to  above,  we  have  a  large  number  of  methods  of 
treatment  offered  us,  in  which  particular,  the  profession  is 
widely  at  variance.  I  think  that  Dr.  Woodbridge  has  received 
too  much  attention  at  the  hands  of  the  profession.  If  we  exerted 
our  efforts  to  the  destruction  of  these  Typhoid  germs  and  spent 
less  time  in  the  discussion  of  Woodbridge's  pellets  No.  1,2,3  and 
4,  science  would  be  benefited.  Some  of  our  recent  writers  tell  us 
that  Carbonate  of  Guiacoal  remains  as  such  in  the  small  intes- 
tine and  will  act  as  an  antiseptic  to  the  intestinal  tract.  At 
best,  it  is  only  a  mild  antiseptic  and  I  doubt  very  much  if  the 
good  effect  of  the  drug  along  this  line  will  counteract  its  bad  ef- 
fect by  interfering  with  digestion.  As  yet,  an  ideal  intestinal 
antiseptic  has  not  been  discovered.  Neimeyer  and  other  Ger- 
man authors  a  good  many  years  ago  advocated  the  use  of  large 
doses  of  calomel,  — 10  to  20  grains  in  the  beginning  of  Typhoid 
Fever.  I  think  it  not  only  wise  and  safe  to  give  these  good- 
sized  doses  in  the  beginning  of  the  disease,  but  it  is  equally  as 
wise  to  give  repeated  and  smaller  doses,  especially  during  the 
first  weeks  of  the  attack. 


^CA  FLETCHER -REPORT  ON  PRACTICE  OF  RIEDICINE. 

Osier  says  that  his  cases  which  are  constipated  get  along  best. 
He  is  very  careful  not  to  follow  up  the  suggestion  and  advise 
that  we  produce  a  condition  of  constipation  in  all  cases.  My 
present  belief  is  in  free  catharsis,  especially  in  the  beginning, 
large  quantities  of  water  internally  and  externally,  and  water 
as  cold  as  the  patient  can  bear  it.  It  is  difficult  to  state  how 
often,  if  we  can  at  all,  abort  typhoid  fever;  but  I  do  know  in 
my  own  section,  a  large  number  of  cases  of  typhoid  fever  or 
typhoid  infection  will  either  abort  or  run  its  course  in  from  lo 
to  14  days.  It  may  be  argued  that  wher»  typhoid  fever  aborts 
or  runs  a  short  course  that  there  is  a  mistaken  diagnosis.  The 
symptoms  are  always  such  as  to  warrant  a  diagnosis  of  typhoid 
fever.  The  fever  might  be  mistaken  for  malaria,  but  no  com- 
petent observer  has  ever  diagnosed  a  case  of  malaria  in  North 
Carolina  west  of  the  Blue  Ridge  among  our  native  population 
who  do  not  leave  the  mountains. 

Your  attention  was  called  to  the  blood  or  serum  test  of  Widal 
for  typhoid  fever  at  our  last  annual  meeting.  After  being  em- 
ployed for  a  year,  it  shows  just  enough  elements  of  uncertainty 
to  make  it  of  little  value  to  the  general  practictioner.  We  had 
hoped  that  we  had  a  test  which  v^^as  absolute  in  the  early  stages 
of  typhoid  fever.  The  blood  examinations  fail  to  confirm  the 
diagnosis  in  about  12  per  cent  of  cases.  The  test  works  on  the 
blood  shows  the  agglutination  in  about  12  per  cent  of  cases 
which  are  not  typhoid,  and  often  the  test  proves  of  value  only 
during  convalescence.  Like  sputum  examinations  in  pulmonary 
tuberculosis  if  the  baccilli  are  found  it  is  helpful,  if  not  found 
the  examination  is  of  little  value.  The  Widal  re-action  can  only 
be  of  value  in  certain  doubtful  and  puzzling  cases,  and  only 
then  when  we  are  near  a  well  equipped  laboratory  in  the  hands 
of  an  expert. 

The  most  remarkable  advancement  in  medicine  in  modern 
times  is  the  good  results  obtained  by  thyroid  treatment  in  cases 
of  sporadic  cretinism  and  in  myxoedema ;  up  to  a  short  time  ago, 
these  subjects  received  little  or  no  attention  at  the  hands  of  the 
general  practitioner.  In  fact,  the  cases  were  so  few  that  they 
were  not  diagnosed  outside  of  institutions.  Since  the  thyroid 
treatment  has  come  into  vogue,  a  greater  number  of  cases  are 
being  discovered,  and  like  appendicitis,  which  up  to  a  few  years 


FLETCHER^REPORT  ON  PRACTICE  OF  MEDICINE.  ,r  r 

ago  was  a  rare  disease,  in  future  our  medical  journals  will  teem 
with  reports  of  cases.  In  all  seriousness,  however,  if  such  good 
men  as  Osier  can  be  believed  (and  he  is  not  an  extremist  on  any 
subject),  the  cures  reported  in  cases  of  sporadic  cretinism  are 
simply  marvelous.  When  we  think  of  the  arrest  of  development 
of  mind  and  body  in  these  cases,  their  idiotic  expression,  the 
unspeakable  affliction  to  their  parents  and  relatives,  and  the 
changes  that  we  are  enabled  to  bring  about  with  what  may  be 
called  a  specific  remedy,  the  dessicated  thyroid  gland,  it  is  one 
of  the  evidences  that  medicine  is  a  progressive  science. 

Osier,  in  his  admirable  paper  on  this  subject,  has  well  nigh 
proven  that  endemic  as  well  as  spordaic  cretinism  results  from  a 
loss  of  function  of  the  thyroid  gland.  The  thyroid  treatment 
is  not  of  less  value  in  cases  of  myxoedema  and  these  cases  also, 
Dr.  Allen  McLane  Hamilton  says,  are  of  more  frequent  occur- 
rence than  is  supposed.  I  was  inclined  to  doubt  the  value  of 
the  remedy  when  my  attention  was  first  called  to  it,  and  fancied 
that  I  could  see  some  resemblance  between  the  principle  involved 
in  the  action  of  the  thyroid  gland  and  Dr.  Brown  Sequard's  elixir 
which  brought  medicine  somewhat  into  ridicule,  and  I  thought 
its  fate  would  be  the  same  as  most  new  remedies  which  had  been 
introduced  in  the  past  few  years;  but  I  had  occasion  to  witness 
the  use  of  the  remedy  in  a  well  marked  case  of  myxoedema,  and 
while  the  case  has  not  been  cured,  the  whole  appearanc  of  her 
countenance,  skin  and  complexion,  has  changed,  and  she  seems 
entirely  relieved  as  long  as  she  is  under  the  specific  influence 
of  the  thyroid  extract.  She  began  first  by  taking  three  grains 
three  times  daily  and  continued  till  she  became  markedly  nervous 
and  had  symptoms  of  hysteria ;  remedy  was  discontinued  till 
nervous  symptoms  subsided  ;  remedy  was  renewed,  five  grains 
daily  with  same  beneficial  effects;  occasionally,  the  patient 
becomes  very  nervous  and  the  remedy  is  discontinued  for  a 
time. 

The  X  ray  is  continuing  to  excite  interest  in  the  profession, 
although  its  use  has  not  fulfilled  first  expectations,  while  is  has 
proven  of  unmistakable  aid  to  the  surgeon,  it  is  going  to  occupy 
a  place  in  medicine  as  an  aid  to  diagnosis.  In  diagnosis  of 
thoracic  diseases,  it  has  proven  of  greatest  value.  Those  who 
are  thoroughly  familiar  with  the  use  of  the  fluoroscope,  not  only 


^eg  BURROUGHS— PREVENTION  OF  TUBERCULOSIS. 

report  no  harmful  effects  to  the  patient,  but  in  a  number  of 
instances,  it  gives  more  accurate  information  concerning  the 
location  and  extent  of  disease  than  we  can  detect  in  any  other 
way. 

"Dr.  Francis  Williams  of  Boston,  in  summing  up  the  ad- 
vantages of  the  use  of  the  X  ray,  claims,  (first)  a  given  part  of 
the  chest  may  be  darker  than  normal  on  account  of  the  ob- 
struction offered  to  the  passage  of  the  rays  which  is  due  to  the 
increase  of  density  that  occurs  in  tuberculosis,  pneumonia, 
infarction,  oedema,  congestion  of  the  lungs,  aneurisms,  new 
growths,  or  to  fluid  in  the  pleural  or  pericardial  sacs;  (second) 
a  given  part  of  the  chest  may  be  brighter  than  normal  because 
it  is  more  permeable  than  in  health  by  the  X  rays  on  account  of 
the  diminution  in  density  due  to  increase  in  the  amount  of  air 
in  the  lungs  in  case  of  pneumothorax  or  increase  the  amount  of 
air  entering  the  thorax  and  displacing  the  lung.  The  normal 
diaphragm  lines  which  can  be  observed  by  the  fluoroscope  is  of 
importance  in  diagnosing  thoracic  troubles.  These  lines  vary 
on  both  sides  of  the  chest  in  disease  and  include  position,  ex- 
cursion and  curve  of  diaphragm  and  the  clearness  with  which 
they  are  seen.  The  fluoroscope  gives  us  better  assurance  that 
the  lungs  are  in  a  healthy  condition  than  other  methods  of 
physical  examination." 

The  most  interesting  part  of  my  subject,  serum — therapy, 
will  be  presented  to  you  by  my  friend,  Dr.  Minor,  who  has 
kindly  consented  to  write  on  this  branch. 


A  FEW  SUGGESTIONS  ON   PREVENTION   OF  TUBER- 
CULOSIS.* 

By  J.  A.  Burroughs,  M.  D.,  Asheville,  N.  C. 


THERE  has  been  so  much  written  on  the  subject  of  tubercu- 
losis since    Professor  Koch   in    1882   first   discovered   the 
germ    that  causes  consumption,    we  hesitate    in   opening 
any  phase  of  the  subject,  yet  we  are  excusable  when  we  state, 
from    statistics,    that   this   is  a  disease   that  causes  the  death  of 

*Read  at  45th  Annual  Meeting  of  the  North  Carolina  Medical  Society,  Char- 
lotte, May  3,  189S. 


BTIRROtrGHS-PREVENTION   OF  TUBERCULOSIS.  -r-j 

every  seventh  human  being  on  the  globe,  and  further,  if  proper 
precaution  and  sanitary  regulations  were  observed,  in  a  short 
time  the  number  of  cases  could  be  greatly  reduced  and  longevity 
raised  several  years. 

All  admit  that  tuberculosis  is  an  infectious  disease,  and  at  the 
same  time  must  admit  that  all  contagious  and  infectious  diseases 
could  be  prevented  if  we  only  knew  what  to  do. 

Located  as  I  am,  handling  hundreds  of  these  cases  from  every 
quarter  of  the  United  States  and  Canada,  it  is  appalling  to  note 
the  lack  of  knowledge  of  the  contagiousness  of  tuberculosis  and 
the  great  danger  the  infected  are  to  others.  It  is  no  infrequent 
occurrence  foi  a  tubercular  mother  to  expect  to  keep  a  baby  and 
a  few  small  children  in  her  bedroom  as  no  protest  has  been  en- 
tered against  the  practice  by  family  physicians  at  home. 

As  soon  as  a  diagnosis  of  tuberculosis  is  made,  first  of  all, 
without  an  exception,  it  should  be  communicated  to  the  patient, 
at^d  he  should  be  informed  of  all  known  facts  on  contagiousness 
of  the  disease  so  that  he  v>/ould  not  be  a  source  of  danger  to 
others  or  reinfect  himself.  The  sputa  is  the  principal  means  by 
which  contagion  is  spread.  All  the  sputa  should  be  collected  in 
a  sanitary  hand  cuspidor  and  the  papers  rem.oved  at  least  twice 
daily  and  exposed  to  a  strong  solution  of  bichlorid  of  mercury, 
or  cremated;  see  to  the  thorough  destruction  of  these  papers  or 
sputa,  do  not  allow  them  to  be  thrown  into  the  sink  to  infect 
people  or  cattle  miles  away;  do  not  permit  a'  blaze  to  consume 
the  dry  portions  of  paper,  leaving  the  sputa  with  its  millions  of 
germs  unmolested  to  dry  and  do  their  deadly  work;  make  the 
patient  understand  that  it  is  the  sputa  you  wish  to  have  thor- 
oughly burned. 

Patients  in  the  first  stage,  in  fact  all  stages,  of  the  disease  do 
a  greater  portic.n  of  their  coughing  and  expectorating  on  rising 
in  the  morning  and  it  incurs  no  hardship  to  demand  this  duty 
of  them,  in  which  they  soon  acquiesce. 

About  two  years  ago  the  little  city  of  Asheville,  N.  C.  passed 
an  anti-expectoration  ordinance  (which  was,  so  far  as  I  know, 
the  first  ordinance  of  the  kind  in  this  country)  since  which  time 
one  hundred  and  seventeen  cities  and  towns  in  the  United 
States  have  passed  a  similar  law.  It  has  proven  a  great  educa- 
tional feature  with  the  masses  and  practically  put  a  stop  to  the 


,r3  BURROUGHS-PREVENTION   OF  TUBERCULOSIS. 

dangerous  insanitary  nuisance  of  spitting  upon  the  sidewalks, 
in  the  street  cars  and  public  buildings,  in  the  city  where  the 
anti-expector ition  ordinance  was  originated.  All  cities  that 
have  passed  this  ordinance  have  experienced  trouble  in  enforc- 
ing a  strict  letter  of  the  law,  millionaires  have  instituted  suits 
for  damages  against  corporations  because  of  reproof  and  eject- 
ment for  vulgarly  violating  this  ordinance,  but  this  has  only  had 
a  good,  wholesome,  and  stimulating  effect  upon  the  people;  it 
has  put  them  to  thinking. 

The  poor  consumptive  of  today,  who  is  properly  informed,  is 
careful  with  his  sputa,  he  feels  that  indifference  on  this  point 
may  be  death  to  others,  cause  him  litigation,  or  hasten  a  crisis 
in  his  own  case. 

It  is  an  admitted  fact  that  no  child  is  born  with  tuberculosis, 
yet  they  do  inherit  that  peculiar,  lymphatic,  anemic,  poorly 
nourished  constitution  which  gives  them  but  little  or  no  resis- 
tance when  exposed  ;  to  permit  these  unfortunate  children  to 
reside  in  tubercular  homes  with  like  habits  and  environments  as 
their  infected  parents  or  relatives,  is  nothing  short  of  criminal 
negligence.  Such  children  should  be  removed  to  an  altitude  of 
dry,  rarefied  atmosphere  loaded  with  ozone  and  perpetual  sun- 
shine; in  conducting  them  into  puberty  and  settled  life,  short 
school  hours  should  be  provided,  with  much  time  spent  in  the 
open  air:  this  class  should  be  induced  aud  taught  the  necessity 
of  eating  such  food  as  will  make  blood  and  build  up  good, 
healthy  tissue  cells  so  as  to  give  them  all  possible  means  of  re- 
sisting any  invasion  of  this  dreaded  enemy. 

I  have  at  this  time  under  my  supervision  many  individuals  and 
families  of  a  tubercular  diathesis  who  have  undoubtedly  escaped 
the  disease  by  the  above  suggestion  ;  at  this  moment  I  call  to 
mind  three  younger  members  of  a  New  Jersey  family  of  ten,  all 
of  whom  had  died  in  quick  succession  with  tuberculosis;  these 
three  located  in  western  North  Carolina  eight  years  ago  and  no 
symptoms  of  tuberculosis  have  developed  in  either  of  them,  the 
younger  being  now  two  two  years  older  than  any  one  of  the 
brothers  or  sisters  who  died  in  New  Jersey. 

A  complete  changeof  climate  in  all  tubercular  families  is  wise 
sanitary  advice  and,  to  repeat,  that  change  should  be  a  higher 
altitude  where  the  air  contains  a  quantity  of  ozone  and  perpetual 


BURROUGHS-PREVENTION  OF  TUBERCULOSIS. 

sunshine  and  is  freer  from  gases  and  bacteria.  It  is  judicious  to 
note  here  that  sunshine  and  ozone  are  deadly  to  tubercle  bacilli 
and,  to  this  fact  is  due  immunization  of  the  points  like  Mexico, 
Denver  and  Asheville,  that  have  been  for  years  resorts  for  con- 
sumptives. 

It  is  possible  for  the  well  to-do  class  to  avail  themselves  of  these 
sanitary  precautions,  but  it  is  quite  different  with  those  less  fortu- 
nate. 

What  we  shall  do  with  our  tubecular  poor  is  a  big  question, 
and  one  which  demands  the  most  serious  and  careful  considera- 
tion by  every  State  and  municipal  Board  of  Health;  to  diagnose 
these  cases  and  report  them  to  the  local  Boards  and  have  them 
registered,  does  but  little  good  beyond  the  general  advice  given, 
and  swelling  our  statistics.  What  that  class  needs  is  some  pro- 
vision by  State  or  city  where  they  could  be  placed  under  the  best 
sanitary  regulations  so  as  to  protect  an  innocent  community  and, 
at  the  same  time,  offer  them  the  best  chance  for  an  arrest  or  cure; 
it  is  more  necessary  thai  this  class  should  have  official  care  as  they 
are  largely  ignorant  and  careless,  and  it  is  principally  these  peo- 
ple who  lounge  around  lawns  and  suburban  fiields,  scattering 
millions  of  germs  upon  the  grass  which  infect  fowls,  stock,  and 
milk. 

England  has  greatly  reduced  her  death  rate  of  pulmonary 
tuberculosis  by  providing  hospitals  for  her  poor;  England  has 
eighteen  tubercular  hospitals  with  the  capacity  of  seven  thous- 
and beds. 

With  the  exception  of  the  States  of  New  York  and  Massachu- 
setts there  has  been  no  attempt  at  isolation  of  the  bulk  and  file 
of  tuberculosis  in  this  country,  so  far  as  I  know. 

It  is  gratifying  to  note  tke  good  being  accomplished  in  veteri- 
nary surgery  under  the  various  State  Boards  of  Health  in  point- 
ing out  infected  herds  of  cattle  and  disposing  of  same. 

Every  large  collection  of  people  should  have  a  competent 
bacteriologist  to  keep  a  watch  over  its  meat  and  milk  supply, 
with  an  especial  view  to  prevent  tubercular  infection  ;  this  official 
would  doubtless  save  the  corporation  employing  him,  many  times 
his  salary,  in  pauper  burial  expenses,  to  say  nothing  of  the  pro- 
tection to  human  life. 

Mal-nutrition,  insufficient  food  of  a  poor  quality,  and  over- 
crowding of  tenements  and  public   buildings   are  subjects   that 


-6q  burroughs-prevention  of  tuberculosis. 

are  constantly  confronting  Health  Boards  and  individual  prac- 
titioners; each  is  a  subject  within  itself. 

I  wish  to  say  something  in  be  half  of  our  over-crowded  school 
buildings  and  orphan  homes;  a  glance  at  the  pale,  anemic  faces 
in  a  public  schoolroom  would  convince  the  most  skeptical  of  the 
various  results  of  improper  ventilation.  That  many  children 
become  infected  in  the  vitiated  atmosphere  of  the  schoolroom 
is  a  painful  fact  that  is  only  too  often  brought  to  our  notice. 

If  mountain  air,  containing  as  it  does,  large  quantities  of 
ozone,  is  beneficial,  and  often  curative,  in  tuberculosis,  why  not 
bring  a  similar  condition  to  bear  in  the  insanitary  schoolroom 
or  other  places  where  there  is  assembled  a  large  and  permanent 
collection  of  people. 

It  is  a  somewhat  remarkable  fact  that  ozone,  which  can  be 
generated  by  means  of  an  electric  current  with  comparative 
economy  and  cheapness,  has  not  been  put  to  more  extensive  use 
for  sanitary  and  prophylatic  purposes:  the  extraordinary  germi- 
cidal power  of  ozone  has  long  been  known  and  recognized  by 
the  scientific  medical  world:  the  ozonizing  of  the  schoolroom 
and  public  building  is  a  matter  of  minor  mechanics.  An  ozone- 
generating  apparatus  is  not  expensive  and  can  be  connected  with 
an  electric  dynamo;  with  the  proper  apparatus  the  whole  build- 
ing can  be  impregnated  with  this  germ  destroying  gas. 

In  any  large  assemblage  of  children  some  one  or  more  have 
tuberculosis  which  has  not  been  suspected  by  teacher,  family  or 
consulting  physician.  If  the  ozonizing  of  school  buildings  were 
put  to  practice,  that  source  of  tuberculosis,  with  all  other  con- 
tagious and  infectious  diseases,  would  be  practically  cut  off, 
and  the  children  would  have  a  nice,  sweet,  clean,  nongeim 
fluid  to  breathe:  this  idea  adopted  in  the  school  there  would  be 
fewer  constitutions  prepared  for  tubercular  infection. 

In  my  judgment  no  hospital  or  sanatorium,  either  private  or 
public,  should  be  kept  open  unless  there  was  ample  provision 
for  ozonizing  the  entire  building  from  celler  to  garret.  The 
statistics  of  mortality  from  tuberculosis  in  insane  asylums  and 
prisons  of  the  different  states,  is  sufficient  to  suggest  a  consid- 
eration of  the  above  idea;  all  must  acknowledge  that  something 
is  wrong  when  strong  men  in  a  few  moths  after  incarceration 
become  tubercular.     With  an  ample  ozonizing  apparatus  placed 


BURROUGIIS-PlffiVENTlON  OF  TUBERCULOSIS.  .5  j 

in  these  prisons  and  asylums,  there  would  be  marked  dininution 
of  tuberculosis. 

The  ozonizing  of  all  hotels  and  especially  Pullman  cars  is  the 
most  rational  solution  of  the  danger  along  that  line.  Permit 
me  to  state  that  in  one  of  the  "babies  wards"  of  New  York  Post- 
graduate Hospital  where  an  ozone-generative  apparatus  is  used, 
contagious  diseases  are  almost  a  curiosity,  whereas  in  non-ozoned 
wards  quite  a  number  have  occurred. 

Soreie  ingenious  pathologist  has  stated  that  the  consumptive 
cadaver  contains  about  eleven  million  tubercle  bacilli:  am  not 
prepared  to  substantiate  or  deny  the  above  statement,  yet  it  is 
quite  reasonable  to  presume  that  the  calculation  is  approximately 
correct:  we  do  know  that  these  bacilli  will  live  in  the  ground 
for  more  than  a  quarter  of  a  century,  retaining  all  the  vitality 
of  the  same  germ  that  was  carelessly  deposited  in  the  hotel  lobby 
the  day  before;  knowing  this,  it  does  seem  reasonable  and  prac- 
ticable, from  a  prophylactic  and  sanitary  position,  that  all  tuber- 
cular dead  should  be  cremated  ;  to  bury  this  class  means  to  infect 
the  soil  and  contaminate  dependent  water  supplies  for  man  and 
beast  for  more  than  a  generation  ;  a  concerted  action  of  all  the 
civilized  world  in  cremating  its  tubercular  dead  might  not  have 
much  effect  upon  this  generatior  but  would  lessen  the  dreaded 
disease  for  those  who  come  after  us. 

There  are  many  points  of  vital  value  on  prevention  of  tuber- 
culosis left  out  ot  this  little  paper  which  I  trust  may  be  brought 
out  in  the  discussion. 

The  laity,  as  well  as  the  profession,  is  wakening  up  to  the  con- 
tagiousness of  this  disease  and,  in  the  judgment  of  some  of  our 
best  thinkers,  there  will  soon  be  a  pronounced,  recognizable 
reaction  in  the  number  of  the  tubercular;  indeed  a  preceptible 
reaction  has  already  begun,  as  is  observed  for  an  editorial  in 
the  Journal  of  the  American  Medical  Association  of  February 
26th,  1898,  where  the  statistics  from  twenty  of  our  principal 
cities  having  a  population  of  seven  million  and  five  hundred 
thousand,  have  shown  a  decrease  of  the  tubercular  death  rate 
thirty-three  per  cent  since  1888,  which  is  tersely  ascribed  to  a 
more  general  knowledge  of  the  contagiousness  of  the  disease, 
better  food  supply,  and  more  perfect  sanitation. 

DISCUSSION. 

Dr.  Kent: — After  this  paper  read  by  Dr.    Burroughs,   I   feel 


»g2  BURROUGHS— PRE VENTIOX  QF  TUBERCULOSIS. 

my  inability  to  add  more  than  simple  emphasis  to  the  position 
taken  by  him,  but  I  do  ivish  to  emphasize  the  matter  of  preven- 
tive measures  in  tuberculosis.  It  tubercular  phthisis  be  a  con- 
tagious infectious  disease,  then  it  is  preventable,  and  if  preven- 
table, it  behooves  us  as  custodians  of  the  public  health  to  bestir 
ourselves  that  something  effective  may  be  done.  Dr.  Koch  some 
sixteen  years  ago  demonstrated  the  fact  of  the  causal  relation 
of  bacillus  tuberculosis  to  consumption.  During  that  sixteen 
years  of  time,  the  m.ost  able  scientists  have  been  confirming  his 
conclusions.  That  there  are  some  who  still  doubt,  we  must  ad- 
mit, but  wiiile  we  admit  it,  I  can  frankly  say  iL  is  well  for  us 
that  there  are  those  .vho  have  doubts.  Ii  makes  discoverers 
more  careful,  it  makes  them  more  painstaking,  anrl  stimulates 
research,  but  the  fact  that  there  are  those  who  doubt  does  not 
disprove,  ar.d  it  stands  today  among  the  best  of  the  profession  a 
well  admitted  fact  that  consumption  is  a  contagious  disease. 
Then,  if  contagious,  what  must  we  do?  Shall  weasklhe  Legis 
lature  lo  pass  laws?  In  my  opinion  we  must,  but  before  we  can 
enforce  laws,  we  must  have  the  moral  support  of  the  people,  and 
in  order  to  have  the  moral  support  ot  the  public,  we  must  edu- 
cate them.  We  as  leaders  in  this  fight  must  teach  it  to  the  peo- 
ple, we  must  teach  it  in  season  and  out  of  season,  and  so  preach 
it  that  thp  people  will  learn  it,  and  that  once  having  learned  it, 
they  can  put  it  into  practice,  for  nothing  is  of  value  that  cannot 
be  put  into  practical  use.  I  am  glad  to  be  able  to  say  that  our 
higher  institutions  of  learning  are  already  armed  and  equipped 
with  proper  information  on  this  subject.  I  have  had  some  little 
correspondance  with  our  best  equipped  institutions,  and  I  find 
that  they  are  already  enforcing  proper  sanitary  regulations  in 
regard  to  this  disease.  I  am  proud  that  it  is  a  fact.  These  are 
the  fountain  heads  of  knowledge  in  our  State,  and  from  them  it 
will  gradually  trickle  down;  but,  gentlemen,  more  may  be  done, 
and  more  may  be  done  quickly,  hi  should  be  taught  in  the 
homes,  it  should  be  taught  in  the  common  schools,  it  should  be 
taught  in  the  high  schools,  it  should  be  taught  in  the  colleges, 
it  should  be  taught  in  the  hotels  and  boarding-houses,  it  should 
be  taught  in  the  church  and  in  the  State,  and  we  can  continue 
so  to  teach  and  so  to  preach  it  that  the  people  Vv'ill  be  ready  to 
join  hands  with  us  in  the  battle  against  this  arch  enemyto  home 
life.  If  we  once  get  the  people  educated  upon  the  subject,  then 
we  are  ready  for  strict  laws,  and  these  laws  will  be  enforced. 
Gentlemen,  it  behooves  us  to  teach  them.  Once  we  have  taught 
them  this,  with  willing  hand  and  educated  brain  and  determined 
mind,  they  will  take  up  the  work  with  us,  and  with  one  common 
cause  we  can  go  on  to  the  extermination  of  this  greatest  enemy 
to  human  life. 

Dr.  Lewis:— \  wdsh  to  express  my  gratification  at  the  excellent 
paper  read  by  Dr.  Burroughs,  and  the  no  less  excellent  remarks 


BURROUGHS— PREVENTION  OF  TUBERCULOSIS,         ^Q  ■, 

of  Dr.  Kent.  I  think  he  has  struck  the  key  note  when  he  speaks 
■  of  the  profession  as  the  custodian  of  the  public  health.  I  do  not 
think  that  anybody  can  deny  that  every  physician  is  a  health 
officer  morally  whether  he  is  really  so  or  not.  It  is  a  simple 
matter  of  education.  Laws  amount  to  nothing  unless  the  peo- 
ple ^e  willing  to  carry  them  out.  There  are  one  or  two  practical 
things  I  think  we  could  carry  out  Vv'ithout  any  trouble  if  we 
would  simply  call  attention  to  them.  The  ordinance  against 
spitting  in  the  street  in  Asheville  is  very  well,  and  I  am  glad 
that  the  laws  of  the  city  of  Asheville  have  done  that.  You  all 
know,  as  Dr.  Burroughs  said,  that  sunshine  and  ozone  are  fatal 
to  the  life  of  the  tubercle  baccillus.  People  spitting  out  in  the 
street  out  in  the  open  air  is  not  so  dangerous  as  spitting  in  the 
houses,  the  dark  unventilated  houses  where  the  bacteria  flourish. 
To  illustrate  that  point,  I  quote  from  the  last  Bulletin  from 
Ohio,  the  history  of  a  house  in  Ohio,  in  which  there  had  been 
three  deaths  from  tuberculosis  evidently  contracted  from  an 
original  case  in  it.  All  these  families  who  moved  mto  the  house 
had  no  hereditary  predispositon  to  the  disease.  This  seems  to 
me  to  be  a  striking  object  lesson,  and  I  am  satisfied  bears  ma- 
terially on  the  subject.  If  the  profession  insisted  upon  it  and  im- 
pressed the  fact  that  tuberculosis  is  a  contagious  disease,  and  that 
if  the  patient  don't  take  the  proper  precautions,  ihey  will  not  only 
die  quicker,  but  will  cause  the  death  of  those  nearest  and  dearest 
to  them,  dearer  to  them  than  their  own  lives,  I  believe  that  there 
will  be  no  difficulty  in  carrying  out  the  proper  precautions.  As 
I  intimated  a  moment  ago,  the  most  important  of  all  is  the 
thoroug^h  disinfection  of  rooms  occupied  by  tubercular  patients. 
If  we  could  ever  get  the  sentiment  instilled  into  the  minds  of 
the  people,  that  under  no  circumstances  should  they  rent  a  house 
in  which  a  case  of  consumption  had  lived  ,  unless  that  house  had 
been  thoroughly  disinfected  and  an  official  certificate  .to  that 
effect  be  presented,  I  believe  it  would  have  a  very  great  effect. 
Of  course  isolation  of  tuberculous  patients  is  desirable,  but 
practically  it  cannot  be  done.  You  can't  take  children  away 
from  parents,  and  the  poor  you  can't  manage  because  we  haven't 
the  money,  and  we  all  know  that  public  sentiment  in  North 
Carolina  is  not  ready  for  making  an  appropriation  to  take  care 
of  consumptives.  If  the  profession  would  impress  upon  the 
people  the  fact  that  tuberculosis  is  a  contagious  disease  and  that 
general  sanitary  precautions  should  be  taken,  and  above  all  ab- 
solute and  thorough  disinfection  and  ventilation  of  rooms,  which 
can  be  most  easily  done,  I  believe  great  good  can  be  accom- 
plished. 

Dr. .-—The    discussion    of    this  paper  has   so    fully 

covered  the  ground  that  I  have  very  little  to  say.      I  rise  simply 
to  endorse  what  the  doctor  has  said  and  what  has  been  said  by 


264  BURKOUGHS— PREVENTION   OF   TUBERCULOSIS 

the  gentlemen  who  preceded  me.  I  think,  sir,  that  we  cannot 
ring  changes  upon  the  prevention  of  tuberculosis  too  often. 
Every  gentleman  who  has  spoken  has  emphasized  the  necessity 
of  educating  the  public  along  this  line,  and  the  only  way  we 
can  educate  the  public  is  to  keep  talking  about  it.  I  do  not  be- 
lieve we  can  spend  an  hour  more  profitably  in  any  medical  meet- 
ing than  in  discussing  this  prevention  and  means  of  preventing 
tuberculosis.  One  or  two  points  I  would  like  to  call  special  at- 
tention to.  One  is  the  practical  matter  of  preventing  tubercu- 
losis among  physicians  themselves.  I  think,  if  you  will  excuse 
the  personal  reference,  that  I  inherited  a  tubercular  tendency 
from  my  father.  Every  time  I  go  to  see  a  tubercular  patient, 
it  hangs  over  me  like  a  terrible  nightmare,  and  after  every  visit 
I  take  the  precautions  to  wash  my  hands  and  my  face,  and  par- 
ticularly my  beard,  because  it  is  by  these  means  that  the  bacilli 
ma.y  be  conveyed  into  the  lungs.  I  think  that  the  very  reason 
that  tuberculosis  is  so  mildly  infectious  constitutes  its  most  dan- 
gerous element.  It  we  could  show  that  it  is  as  infectious  as 
scarlatina  or  diphtheria,  we  might  hope  alter  a  lirtle  while  to 
take  up  some  practical  measure  and  insist  on  instituting  meas- 
ures to  prevent  it,  but  it  is  because  it  is  so  mildly  infectious  that 
we  have  such  a  hard  time  to  educate  the  public.  But  to  return 
to  the  point  which  I  just  mentioned,  and  that  is  tuberculosis 
among  physicians.  We  all  have  seen  it,  and  we  have  all  had 
friends  who  have  had  it  and  have  died  of  it.  The  practical 
question  comes,  how  did  they  contract  it?  It  is  quiie  possible 
that  we  might  set  a  good  example  to  the  laity  by  instituting 
some  reforms  ourselves,  and  in  that  way  we  could  show  them 
that  it  is  important  that  we  should  disinfect  ourselves.  I  have 
seen  physicians  and  heard  them  talk  about  disinfecting  them- 
selves and  isolating  cases  of  scarlatina,  etc.,  and  yet  this  same 
physician  would  go  to  see  a  case  of  scarlatina  and  yet  wear  the 
same  clothes  and  hat  and  overcoat,  and  never  disinfect  his  hands 
or  face  or  anything  and  go  to  see  another  patient.  I  say  that  we 
can  best  educate  the  public  perhaps  by  instituting  some  reforms 
ourselves  along  this  line. 

Dr.  Spencer  reported  the  case  of  the  keeper  of  the  poor  house 
for  the  aged  and  infirm  in  Caswell  county  who  died  not  quite 
two  years  ago  with  phthisis.  No  family  history  of  phthisis 
whatever.  Since  that  time  two  children  have  died,  and  two  re- 
maining children  now  have  phthisis.  The  wife  now  has  tuber- 
culosis, and  two  laborers  who  were  there  a  while  have  also  tuber- 
culosis, or  rather,  they  did  have  it,  they  are  dead. 

Dr.  Reagan: — I  know  of  a  case  which  I  would  like  to  bring 
before  the  Seciety,  which  I  think  shows  strongly  the  contagion 
of  the  disease.  It  vi^as  that  of  a  gentleman  of  Peoria,,  111,  who 
is  now  at  my  house.  He  was  broken  down  from  hard  work  and 
was  advised  to  go  to  Colorado.      They  examined  him  there  and 


BURROUGHS-PREVKNTION  OF  TUBEKCULOSIS.  ^gr 

pronounced  his  lungs  perfectly  sound.  In  the  hotel  and  in  the 
streets  there  were  no  sanitary  regulations  at  all,  and  the  result 
was  that  after  a  stay  there  of  a  few  months  the  last  examination 
revealed,  as  the  doctor  said,  some  bugs  in  the  sputa.  He  came 
to  my  house  over  eight  months  ago,  and  has  had  no  hemorrhage 
since.  He  weighed  117  pounds  when  he  came  there,  and  now 
he  weighs  137.  I  say  then  let  us  try  to  educate  the  people.  I 
remember  that  about  four  or  five  years  ago  we  discussed  this 
thing  in  the  Medical  Society  in  Asheville,  and  one  physician  who 
was  treating  the  disease  contended  thai  it  was  not  contagious. 
He  said  that  the  attendants  and  nurses  in  the  hospitals  never 
contracted  the  disease.  But  that  idea  has  given  way  and  the 
Medical  Society  of  Asheville  has  been  able  to  pass  an  ordinance, 
endorsed  by  the  town  authorities,  that  prevents  spitting  on  the 
sidewalks  or  in  public  places. 

Dr.  Walton: — I  know  of  a  case  where  the  parents  and  two 
boys  and  two  girls  died  of  pithisis  in  rapid  succession.  After 
this  the  three  living  children  broke  up  housekeeping,  off,  moved 
and  none  of  the  rest  developed  phthisis.  This  is  pretty  strong 
evidence  of  the  contagiousness  of  tuberculosis.  The  mother 
was  not  of  a  consumptive  family,  and  there  was  no  heredity  of 
that  kind  on  her  side.      It  was   hereditary  on    the  father's  side. 

Dr.  Anderson. — I  would  like  to  say  something  in  regard  to  the 
importance  of  making  a  correct  diagnosis  in  these  cases.  Of 
course  all  of  our  patients  who  cough  haven't  consumption  by  a 
long  ways,  and  those  who  don't  cough,  and  very  often  look  well, 
may  have  the  beginning  of  consumption.  I  have  in  mind  some 
few  cases  in  my  own  town  where  it  was  important  to  make  a 
diagnosis  with  the  microscope,  and  we  waited  too  long.  One 
young  man  in  my  own  profession  who  graduated  only  a  little 
over  a  year  ago,  delayed  having  an  examination  made  last  sum- 
mer, and  when  he  did  found  tubercle  bacilli  in  great  abundance. 
I  believe  that  if  he  had  had  that  examination  made  twelve 
months  ago  and  had  taken  the  necessary  piecautions  towards 
stamping  out  the  disease,  and  had  gone  to  some  suitable  climate 
and  taken  tonic  remedies,  using  every  precaution  known  to  him, 
that  perhaps  he  would  have  checked  the  disease  and  been  on  the 
ro-d  to  recovery  to  day.  It  is  a  sad  thing  to  look  at  that  young 
man,  so  well  prepared  for  his  work  and  so  devoted  to  his  pro- 
fession, it  is  the  saddest  picture  in  the  history  of  my  life.  Another 
case  I  have  in  mind  is  that  of  a  young  lady.  She  is  the  very 
picture  of  health,  or  at  least  was  six  months  ago.  She  had  throat 
trouble,  so  her  physician  thought,  with  no  tubercular  trouble 
connected  with  it.  Her  trouble  went  on  until  she  consulted  a 
specialist,  Dr.  C  hisholm,  of  Baltimore,  and  he  treated  her  there 
a  while.  He  asked  for  a  specimen  of  the  sputa,  and  just  about 
the  time  she  sent  it,  she  consulted  her  physician  and  sent  a 
specimen  to  me.      I    examined    it,    and    found   tubercle  bacilli, 


^56         BURROUGHS— PREVENTION  OF  TUBERCULOSIS. 

much  to  my  surprise.  I  never  made  a  physical  examination, 
though  her  doctor  could  discover  nothing.  I  wish  to  press  the 
point  that  it  is  important  to  make  a  bacteriological  examination 
with  the  microscope.  It  is  the  easiest  thing  done  in  bacteriology. 
We  can  absolutely  tell  from  a  stain  of  the  bacilli,  and  we  can 
hardly  say  that  of  any  other  germ,  without  culture.  So  peculiarly 
does  it  retain  its  stain  that  it  is  one  of  the  easiest  examinations  to 
determine.  It  is  an  easy  thing  to,  do  and  I  believe  that  any  doctor 
could  learn  how  to  do  it  in  just  a  few  hours  time  witha  suitable 
magnifying  lens. 

Dr.  Hunter. —  I  rise  to  inquire  for  information.  If  tubercu- 
losis is  so  contagious  and  so  contaminating,  why  is  it  that  we 
never  find  our  patients  in  the  beginnig  of  the  disease  at  the  age 
of  50  or  60  years?  I  have  never  seen,  to  my  own  knowledge,  a 
case  of  tuberculosis  that  has  been  contracted  after  the  age  of  50 
or  60  years.  If  tuber':ulosis  is  so  contagious  and  so  coniaminut- 
Ing  to  younger  persons,  it  seems  to  me  that  in  the  older  and 
more  depleted  frame,  it  would  be  more  so.  I  would  like  to  have 
some  light  on  this  subject. 

Dr.  Carr — recited  an  instance  in  Switzerland  where  a  soldier 
contracted  consumption  abroad  and  coming  to  his  mountain 
home,  his  wife  took  the  disease,  both  dying.  A  regular  epidemic 
ensued,  and  an  eminent  French  physician  who  investigated  the 
matter  came  to  the  conclusion  that  the  disease  was  spread  by 
eating  chickens  which  were  sold  about  the  place  by  the  father 
of  the  woman.  It  was  known  that  the  chickens  were  in  the 
habit  of  eating  the  sputa  hwich  the  woman  would  expectorate 
upon  the  ground. 

Dr.  Crowell: — It  seems  to  me  almost  im.possible  for  disease  to 
be  communicated  in  that  way,  especially  when  the  chicken  was 
cooked,  as  heat  would  destroy  the  bacilli. 

Dr.  Carr: — We  are  not  certain  that  they  were  cooked.  Some 
people  like  rare  chickens. 

Dr.  Brownson: — I  wish  to  say  a  word  about  the  case  referred 
to  by  Dr  Reagan.  It  seems  to  me  that  that  was  an  instance 
which  would  show  that  great  care  should  be  exercised  in  making 
a  diagnosis  rather  than  showing  that  the  disease  was  contracted 
later.  The  patient  was  said  to  be  broken  down  and  was  sent  to 
Denver,  which  to  me  would  show  that  he  was  suspected  of  a 
tendency  to  tuberculosis,  and  that  the  tuberculosis  was  not  dis- 
covered in  the  examinations,  not  after  he  got  to  Denver.  It 
seems  to  me  it  does  not  prove  that  he  did  not  have  it  when  he 
went.  It  might  be  called  latent  tuberculosis,  or  so  slight  that 
it  was  not  at  first  recognized,  I  frequently  examine  cases  sup- 
posed to  be  tuberculosis  v/ithout  finding  positive  evidence  of  it, 
but  still,  il  I  do  find  it  later,  I  do  not  suppose  that  the  patient 
has  been  infected  since  I  first  examined  him,  but  rather  that  he 
had  it  all  along,  and  I  failed  to  discover  it. 


BURROUGHS— PREVENTION  OF  TUBERCULOSIS,  g 

Dr.  McAf>dian:—\l  is  rather  too  late  for  the  Society  to  discuss 
the  infectiousness  of  tuberculosis  as  it  is  an  accepted  fact.  The 
only  question  !s  as  to  the  degree.  It  would  be  very  nice  if  we 
could  have  as  Dr.  Burroughs  su^ygests,  an  apparatus  in  the  cellar 
to  keep  a  liow  of  ozone  through  the  house,  but  while  this  is  im- 
possible, we  can  have  a  good  supply  of  God's  pure  air  in  which 
there  is  at  all  times  a  supply  of  this  blessed  ozone.  The  great 
increase  of  consumption  among  the  negroes  since  the  v/ar  seems 
to  be  due  to  the  altered  mode  of  living.  In  ante-bellum  days 
they  lived  in  houses  with  big  chimniesin  which  burned  aroarmg 
wood  lire,  which  carried  a  column  of  air  four  feet  in  diameter 
out  of  the  room,  fresh  air  coming  through  the  cracks.  Now 
they  are  huddled  ip  the  cities,  live  in  small  rooms  with  st(jves 
which  give  no  ventilation,  leaving  the  air  stagnant.  The  air  is 
breathed  over  and  over  again,  and  I  would  as  soon  e.xpect  a 
person  to  take  into  his  alimentary  canal  over  and  over  again  his 
own  dejecta  and  not  contract  disease  as  for  iiim  to  breathe  over 
and  over  again  his  pulmonary  exhalations  and  not  suffer.  The 
same  reasoning  applies  to  the  North  American  Indian  who  has 
had  to  change  his  life  in  the  open  air  for  one  of  laziness.  It  ap- 
plies also  to  the  modern  habit  of  building  houses  with  steam 
and  hot  air  heaters.  In  these  homes  the  people  live  and  swtlter 
and  their  skins  are  not  taught  to  resist  the  influence  of  cold.  I 
instruct  my  patients  as  to  the  manner  of  building  their  houses; 
and  I  think  that  we  should  instruct  our  patients  that  at  night 
and  in  the  summer  one  windovv'  should  be  thrown  wide  open  to 
admit  a  good  supply  of  God's  pure  atmosphere. 

Dr.  .• — I  was   interested  in   what  the  gentlemen    said   in 

regard  to  the  cause  to  this,  but  there  seems  to  be  something 
more  than  bad  air.  I  myself  practice  in  the  country,  where  we 
have  the  kind  of  houses  he  described,  open  walls  and  all  that, 
yet  I  think  I  can  say  that  in  eighteen  years  of  practice  that  one- 
third  of  deaths  I  have  had  among  this  negro  population,  has  oc- 
curred from  tuberculosis,  in  these  open  houses  and  in  the  open 
c(nintry.  There  seems  to  me  to  be  some  other  caube  possibly 
because  they  are  badly  clothed  and  badly  fed.« 

Dr.  McMiiIlin: — I  do  not  claim  an  instant  that  bad  air  will 
give  a  man  consumption.  I  simply  contend  that  it  harbors  the 
germs  in  concentration,  and  that  it  therefore  makes  you  more 
vulnerable.  Most  of  these  darkies  go  co  church  and  sit  for  hours 
and  hours  in  this  vicious  atmosphere. 

Dr.  Burroughs: — I  thank  the  gentlemen  very  heartily  for  their 
discussion  of  this  paper.  It  has  met  the  ends  for  which  it  v/as 
written.  I  wish  to  say  this,  that  a  tubercular  patient  is  not  con- 
sidered dangerous  to  other  patients  as  long  as  he  is  careful  of 
his  sputum.  The  physician  attending  and  the  nurses  who  nurse 
the  tubercular  patients  are  in  the  least  danger  of  any  of  the  con 
tagious  and  infectious  diseases,  because  it  is  so  easy   to   control 


^58  BURROUGHS-PREVENTION  OF  TUBERCULOSIS. 

by  destruction  of  the  sputum.  I  can  say  this,  that  I  appreciate 
the  remarks  of  Dr.  McMullan  on  thorough  ventilation.  If  we 
have  the  old-fashioned  chimney,  open  doors  aid  window^s.  and 
plenty  of  sunshine  and  fresh  air,  we  get  a  plenty  of  ozone  in 
our  atmosphere,  and  ozone  and  sunshine  are  what  kill.  One 
point  has  not  been  brought  out,  on  which  I  wish  to  lay  emphasis. 
It  is  this,  that  every  room  which  has  been  occupied  by  a  con- 
sumptive should  be  disinfected  as  thoroughly,  and  sterilized,  as 
if  death  from  consumption  had  occurred  in  that  room.  It  is  bad 
sanitation  to  allow  consumptives  to  move  from  house  to  house 
and  oiIkm's  move  into  the  rooms.  In  Asheville  we  have  every 
consumptive  registered  and  we  have  him  give  his  residence  to 
the  Board  of  Health,  and  if  he  moves  his  res^idence,  we  have  the 
Board  of  Health  notified,  and  the  physician  who  is  up  to  his 
business  sees  to  a  thorough  sterlization  and  disinfection  of  the 
rooms  after  the  patient  has  gone.  When  our  patients  come  to 
us,  wc  see  thac  they  come  into  a  room  that  is  thoroughly  steri- 
lized. We  do  not  sterilize  our  rooms  with  ozone.  That  is  for 
larger  institutions.  The  cheapest  and  best  way  to  sterilize  a 
room  where  a  consumptive,  or  any  other  contagious  and  infec- 
tious disease  has  been,  is  by  means  of  sulphur.  Eight  pounds 
of  sulphur  burned  in  a  room  15  x  15  and  burned  eight  hours, 
will  sterilize  it. 

In  reply  to  a  question  as  to  the  manner  of  using  sulphur  Dr. 
Burroughs  said  dry  sulphur  fumes  would  kill  the  germs.  How- 
ever Dr.  Fletcher  stated  that  as  a  matter  of  fact  steam  was 
always  generated  along  with  the  burning  of  the  sulphur,  and  he 
believed  the  dry  sulphur  worthless.  In  regard  to  formaldehyde, 
he  had  not  experimented  with  it  himself,  but  referred  to  the  re- 
port of  the  President  of  the  Board  of  Health  of  a  western  state, 
whose  experiments  showed  it  to  be  unsatisfactory  in  disinfecting 
rooms  infected  with  tubercle  bacilli. 


NORTH  CAROLINA  MEDICAL  JOURNAL. 

ROBERT  D.   JEWETT,  M.D.,  Editor 

DEPARTMENT  EDITORS 

i      H.  T.  Bahnson,  M.D.,  Salem,  N.C. 
SURGERY:      \      R.  L.  Gibbon. M.D.,  Charlotte,  N.  C. 

/      J.  Howell  W  ay,  M.D.,  Waynesville,  N.  C. 

NERVOUS  DISEASES:— J    LLISON  HoDGES.  M.D.,  Rcihmond,  Va. 


PRACTICE  OF  MEDICINE. 


S.  Westry  Battle.  M.D.,  U.  S.  N. 
Asheville.  N.  C. 


(      George  G.  ThOxMAS,  M.D.,  Wilmington,  N.  C, 
ut.bit.iniLS5.      ^     R.  L.  Payne,  M.D.,  Norfolk,  Va. 

(      H.  S.  LOTT,  M.D.,  Winston.  N.  C. 
GYNAECOLOGY:     \     J.  W.  Long.  M.D..  Salisbury,  N.  C. 
(      H.  A.  ROYSTER,  M.D.,  Raleigh,  N.  C. 

PATHOLOGY:— Albert  Anderson.  M.D..  Wilson.  N.  C. 
PEDIATRICS:— J.  W.  P.  Smithwick,  M.D.,  La  Grange,  N.  C. 
TRANSLATION  AND  FOREIGN  REVIEWS: 
Richard  H.  Whitehead,  M.  D.,  Chapel  Hill,  N.  C. 


All  communications,  either  of  a  literary  or  business  nature,  should  be 
addressed  to,  and  any  remittances  by  P.  O.  Order,  Draft  or  Registered  Let- 
ter, made  payable  to  Robert  D.  Jewett,   M.D.,  Winston,  N.  C. 

leMtonal. 


THE  SOCIETY  MEETING. 


The  forty-fifth  annual  meeting  of  the  State  Society  is  now  a 
matter  of  history.  Beautiful  weather  and  the  well  known  hos- 
pitality of  the  people  of  the  Queen  City  tempted  out  a  good 
attendance,  and  those  who  came  were  not  disappointed.  The 
sessions  were  held  in  the  new  court  house  which  proved  one  of 
the  most  comfortable  meeting  places  the  Society  has  ever  assem- 
bled in.  Clean,  cool  and  roomy,  and  well  removed  from  the 
din  and  rattle  of  paved  streets,  it  was  a  real  pleasure  to  sit  and 
'.tsten  to  the  many  interesting  papers  that  were  presented  by 
some  of  the  Society's  best  members.      It  was  a  noteworthy  fact, 


27  O  KDITORIAL. 

as  showing  the  trend  of  medical  workers  at  this  day,  that  the 
most  prolonged  discussions  were  upon  those  papers  treating  of 
the  prevention  of  disease. 

The  suggestions  of  the  President  in  regard  to  the  admission 
of  licentiates  of  the  Board  of  Examiners  was  productive  of  good 
results,  the  new  members  admitted  at  this  meeting  numbering 
fifty-five.  At  least  one-half  of  the  number  licensed  connected 
themselves  with  the  Society,  and  it  is  quite  certain  that  nearly  all 
of  these  will  take  an  interest  in  the  Society  and  make  valuable  and 
influential  members.  •  How  much  better  thus,  than  that  they 
should  be  allowed  to  drift  away  and  wait  to  join  until  the  So- 
ciety should  happen  to  meet  in  their  respective  neighborhoods. 
Again,  as  it  has  repeatedly  done  before,  the  Society  refused  to 
permit  admission  of  members  by  proxy.  This  may  be  a  wise 
thing  to  do,  but  we  candidly  admit  we  do  not  see   it  that   way. 

This  year  sees  quite  a  change  in  the  personnel  of  the  State 
Board  of  Medical  Examiners.  There  were  two  vacancies  caused 
by  expiration  of  terms  of  service  of  Dr.  J.  M.  Baker  and  Dr. 
H.  B.  Weaver.  These  were  filled  by  the  Society,  Dr.  Albert 
Anderson,  of  Wilson,  and  Dr.  E.  C.  Register,  of  Charlotte,  be- 
ing elected.  Two  vacancies  were  caused  by  the  resignation  of 
Dr.  R.  H.  Whitehead,  of  Chapel  Hill,  and  Dr.  T.  S.  Burbank, 
of  Wilmington.  These  vacancies,  in  accordance  with  the  State 
law,  were  filled  by  the  Board,  Dr.  J.  Howell  Way,  of  Waynes- 
ville,  being  elected  to  succeed  Dr.  Whitehead,  and  Dr.  W.  H. 
H.  Cobb,  of  Goldsboro,  to  succeed  Dr.  Burbank.  The  newly 
elected  members  are  well  known  and  will  reflect  credit  upon  the 
Society.  We  congratulate  them  upon  having  bestowed  upon 
them  the  most  responsible  gift  in  the  possession  of  the  Society. 

It  is  useless  to  say  aught  of  the  new  President,  Dr.'  L.  J. 
Picot,  of  Littleton,  but  we  are  tempted  not  to  wait  until  he 
joins  the  great  majority  to  say  of  him  "None  know  him  but  to 
love  him,  none  name  him  but  to  praise."  As  he  is  a  man,  so 
will  he  make  a  president,  s//t  generis. 

Our  readers  will  not  fail  to  notice  that  this  issue  of  the  Journal 
is  twice  the  usual  size  and  devoted  almost  entirely.to  the  Society 
proceedings.  The  next  issue  will  be  likewise  enlarged.  In  this 
connection  we  will  say  that  we  acknowledge  with  the  highest 
appreciation    the   unanimously    favorable  action    taken   by  the 


NECROLOGY.  , - j 

Society  in  regard  to  the  Journal.  In  high  ethical  standing^  pro- 
gressiveness  and  practical  usefulness  the  Journal  will  continue 
striving  to  make  itself  worthy  of  being  the  mouthpiece  of  so 
distinguished  and  able  a  body  as  the  Medical  Society  of  North 
Carolina. 


ARE  YOU  GOING  TO  CUBA? 


If  so,  the  Alkaloidal  Clinic  offers  the  following  very  timely 
suggestions:  The  pernicious  effects  of  tropical  climates  are  very 
muck  exaggerated.  There  are  but  few  rules  to  be  observed  by 
strangers  and  they  are  not  difficult.  The  diet  should  be  mostly 
fruits  and  vegetables,  and  meats  and  alcuholic  drinks  are  harm- 
ful; it  is  the  latter  more  than  the  climate  that  cause  "tropical 
liver."  Follow  the  natives'  plan  of  taking  but  little  exercise  in 
the  sunshine.  Avoid  water  that  has  not  been  boiled  or  distilled. 
Keep  in  at  night  and  sleep  well  away  from  the  ground.  Ex- 
cesses of  all  kinds  are  harmful.  Great  stress  is  laid  upon  the 
danger  that  lies  in  the  dark  eyes  of  the  mantilla  clad  senorita; 
"Shun  her  as  you  would  any  other  pestilence." 


NECROLOGY. 


Dr.  Robert  Gibbon. 

Again  the  reaper  Death  has  been  a'  work,  and  cut  down  him 
whose  name  stands  first  on  the  roll  of  the  Medical  Society  of 
the  State  of  North  Carolina.  On  Saturday,  May  14,  1898,  Dr. 
Robert  Gibbon,  of  Charlotte,  N.  C,  ended  a  bright  and  useful 
career.  From  the  Charlotte  Observer  we  glean  the  following 
data: 

The  son  of  Dr.  John  H.  Gibbon,  he  was  born  in  Philadelphia 
in  1822,  and  his  death,  therefore,  came  at  the  age  of  76  years. 
His  father  moved  to  Charlotte  in  1837,  having  been  appointed 
assayer  of  the  United  States  Mint,  which  was  established  the 
year  before.  Dr.  Gibbon  received  his  education  from  various 
schools  in  Mecklenburg,  and  then  attended  Yale.      He  graduated 


--2  READING   NOTICES. 

in  medicine  from  Jefferson  College.  He  came  to  Charlotte  in 
1848,  and  ever  afterward  made  this  his  home.  When  the  war 
broke  out,  Dr.  Gibbon  entered  the  army  as  surgeon 
of  the  Twenty-eighth  North  Carolina  Regiment.  He  was  with 
the  army  in  Virginia  from  '61  to  '64,  and  made  a  reputation  as  a 
surgeon  second  to  none.  He  was  a  man  of  fine  sense,  judgment, 
skill  and  nerve,  all  of  which  qualities  he  found  ample  play  for  on 
the  bloody  fields  of  Virginia.  In  '64  he  was  given  charge  of  the 
military  hospital  in  Charlotte,  and  remained  here  until  the  sur- 
render. 

As  a  physician  and  surgeon  he  had  few  equals  in  this 
State.  He  was  honest  and  upright  in  his  dealings  with  his 
fellow-men  ;  correct  in  his  deportment ;  a  man  of  unquestioned 
ability  and  unsoiled  principles.  He  was  full  of  pleasantries,  and 
was,  by  reason  of  his  agreeable  address  and  manner,  a  good  com- 
panion. He  had  a  large  practice,  and  amassed  considerabl  pro- 
perty. In  faith  he  was  a  Presbyterian.  There  was  no  more 
regular  attendant  upon  the  services  of  the  sanctuary, 
and  none  who  gave  more  heed  unto  private  devotions  thau  he. 

Dr.  Gibbon  was  one  of  the  earliest  members  of  the  State 
Society,  having  joined  in  185 1.  He  was  twice  married,  his 
second  wife  surviving  him,  with  two  sons — Drs.  R.  L.  and  J.  H. 
Gibbon — children  of  the  first  marrige. 


IReaMng  "fflotlces. 

"Coca"  has  maintained  its  reputation  as  a  powerful  nerve 
stimulant,  being  used  with  good  results  in  nervous  debility, 
opium  and  alcohol  habit,  etc.  The  highly  variable  character  of 
the  commercial  drug  makes  it  uncertain  however.  Robinson's 
Wine  Coca  (see  page  2)  we  believe  to  be  a  uniformly  active 
article,  it  being  prepared  from  assayed  leaves,  the  percentage  of 
Cocaine  being  always  determined  by  careful  assay. 


CELERinA  not  only  re- 
noves  fatigue  of  both 
5rain  and  body,  but  it 
s  also  of  the  greatest 
service  to  singers  and 
peakers,  for  whilst 
>racing  the  nerves,  it 
trengthens  the  voice. 


A   sample   bottle   will   be  sent   free  to  any  physician   who  desires  to 
test  It,  if  he  will  pay  the  express  charges. 

RIO  CHEMICAL  CO.,  St.  Louis,  Mo.,  U.  S.  A. 


I 


ISTBRINB 


The  Staodarct  Antisei3ti< 


LISTERINE  i*^  ^  non-toKic,  non-iri-itatin<r  an d-eseharotic  antiseptic,  composed  of  oz^ 

ferous  essences,  vegetable  antiseptics  and  benzo-boracic  acid. 
LISTERINE  is  sufficiently  powerful  to  make  and  maintain   surgical  cleanliness  in 

antiseptic  and  prophylactic  treatment  and  cai-e  of  all  parts  of  the  human  bc5 
LISTERINE  has  ever  proven  a  trustworthy  antiseptic  dressing-  for  operative  or  a< 

dental  wounds. 
LISTERINE  is  invaluable  in  obsteti;ics  and  g-ynecology  as  a  g-eneral  cleansiag.  prop 

lactic,  or  antiseptic  ag^ent.  and  is  an  effective  i-emedy  in  the  treatment  of  cat 

i-hal  canditions  of  every  locality. 
LISTERINE  is  useful  in  the  treatment  of  the  infectious  maladies   which  ai-e  attended 

inflammation  of  accessible  surfaces— as  diphtheria,  scarlet  fever  and  jjertus.- 
LISTERINE  is  especially  applicable  to  the  treatment  of  scarlet  fever,  used  freely  a 

mouth  wash,  or  hy  means  of  the  spray  apparatus. 
LISTERINE  is  extensively  prescribed  in  typhoid  fever  both  for  its  antiseptic  effect  : 

to  improve  the  condition  of  the  stomach  for  the  reception  of  nourishment. 
LISTERINE  agreeably  diluted,  is  prescribed  with  very  good   results,  in  the  treatir 

of  diphtheria,  both  as  a  prophylactic  and  curative — internal  antiseptic — agV 
LISTERINE  is  used  extensively  with  good  results  in  the  treatment  of  whooping-cou: 
L  ISTERNE  diluted  with  water  or  glycerine  speedily  relieves  certain  fermentative  f<^ 

of  indigestion. 
Listerine    is    indispensable    for   the    preservation  of  the  teeth,  and  for  maintaining 

mucous  membrane  of  the  mouth  in  a  healthy  condition.  'f 

Listerine  employed  in  a  sick-room  by  means  of  a  spray,  or  saturated  cloths  hung  a^ 

is  actively  ozonifying  and  imparts  an  agreeable  refreshing  odor  to  the  atmosiihi 
Listerine  is  of  accurately  detei-mined  and    uniform    antiseptic    power    and    of  posil 

originality. 
Listerine  is  kept  in  stock  by  the  leading  dealers  in  drugs  evei-jwhere. 


Lambert's  Lithiatd  Hydrangea, 


C/ose  clinical  observa- 
tion has  caused  Lam- 
bert's Lithiated  Hyd- 
rangea to  be  regarded 
by  Physicians  generally 
as  a  7'ery  valuable  Renal 
Alterative  and  Aitti 
Lithic  Agent. 


ALBUMIISURIA, 
BRIGHT'S  DISEASE. 
CYSTITIS, 

DIABETES, 
GOUT, 

HEMATURIA, 
LITHiE^IIA, 
NEPHRITIS, 

RHEUMATISM, 

URINARY  CALCULUS, 
and  all  forms  of 

VESICAL  IRRITATldS 


For  Descriptive  Literature,  Address 

LAMBERT  PHARMACAL  CO.,St.Loui{ 


5«0TICE.— Thirty-two  Pages  Extra  In  This  Issii^ 


enly-Flrst   Year. 


JUNE  5,  i; 


NORTH  CAROLINA 

MEDICAL  JOURNAL 


PUBLISHED  SEMI-MONTHLY  AT  $2.00  PER  ANNUM. 


IRobert  2)»  Jewett,  Ob,  2).  iBbUor. 


[Entered  at  the  Post-Office  at  Winston,  N.  C,  as  Second-class  mail  matter.j 


If  you  have  any  doubt  whatever  concerning  the  value 
of  Taka  Diastase  as  a  starch  digestant,  we  ask  that  you 
apply  the  following  simple  test: 

Make  a  stiff  jelly  by  boiling  i  drachm  of  potato  starch 
in  3  ounces  of  water,  cool  to  body  temperature,  add  about  i 
grain  of  Taka- Diastase,  and  slir.  The  stiff  jelly  will  be  almost 
instantly  converted  into  a  watery  solution,  and  in  about  15 
minutes  all  the  starch  will  be.  converted  into  sugars. 

Respectfully, 


fO^^i^^.aOi 


a/V'-c^ 


Home  OHIceg  and  Laboratories,  Detroit,  Mich. 

Braocbes  io  New  York,  Kansas  City,  Baltimore,  and  New  Orleans. 


\nti-Tubercle  Serum 

IPAQUIN) 

Anti-Diphtheritic  Serum 

(PAQUIN) 

Anti-Tetanic  Serum 

(PAQUIN) 

Auti-Streptococcus  Serum 

*  (PAQUIN) 


N  Tuberculosis 

D 

c   Diphtheria 
E   Tetanus(LocK.jA^ 

Puerperal  Fever,  Seepticemia,  Mixed  Infections  of  Tube 
I  culosis  and  Diphtherid,  Erysipelas,  Scarlatina,  Pyemia,  Bro 
1^    chitis.  Bone  and  Joint  Tuberculosis. 

^4 


Tuberculin,  Erisypelas  Toxin,  Mallein,  Vaccine  Points.     Cultures  Pathogenic  and  Non-Pathogenic,  Slides  of  Germ 
Outfit  for  Microscopical  Diagnesis  of  Tuberculosis,  Chemic,  Bacteriologic  and  Microscopic  Analyses  Made. 

4^ 

BRONCHURE,  WITH  CLINICAL  REPORTS,  ALSO  VIALS  FOR  MAILING  SPEC 
MENS  FOR  ANALYSIS  SENT  ON  APPLICATION. 

THE  PAUL  PAQUIN  LABORATORIES  CO., 

209  N.  Seventh  St.,  St.  Louis,  Mo 


DOCTOR! 

— ^'    IS      NEITH  ER    '^-^ 

FBENCMHi  GERMAN 
iTis  AMmRICAN 

Made  IN  AMERICA 
For  AMERICANS 


NORTH  CAROLINA 

MEDICAL  JOURNAL. 

SB 

A  SEMI-MONTHLY  JOURNAL  OF  MEDICINE  AND 
SURGERY. 

Vol.  XLI.  Winston,  June  5,    1898.  No.    11. 

©riainal  Communicatione. 


MEDDLESOME  GYN/ECOLOGY. 
By  H.  S.  Lott,  M.  D.,  Salem,  N.  C. 

TJf  UCH  has  been  said  and  written,  with  justice  on  the  subject 
/  \  of  "meddlesome  midwifery."  It  would  be  well  for  the 
profession  to  devote  some  time,  and  thought,  to  meddle- 
some Gyaencology. 

The  experimental  stage  of  this  branch  of  work  is  past;  it  is 
no  longer  a  question  of  haphazard  "uterine  tinkering,"  but  a 
distinctive  and  preeminently  a  special  branch  of  surgery,  wherein 
we  may  determine  with  a  large  degree  of  ceitainty,  knowing 
the  past  history,  what  is  the  pathology  and  prognosis  in  a  given 
case  of  intra- pelvic  disease,  and  the  treatment  which  gives 
greatest  hope  for  the  future  comfort  of  the  patient. 

There  comes  an  era  in  the  march  of  all  progress  wherein  it  is 
well  to  review  what  has  been  done,  being  thus  enabled  to  sepa- 
rate the  good  from  the  bad,  render  more  perfect  the  result  of 
past  work,  and  come  nearer  to  truth,  which  is  the  aim  through 
all,  and  if  in  doing  this  we  set  aside  instruments,  methods  or 
procedures  it  is  not  through  disregard  for  their  originators, 
but  rather  because  we  trust  and  honor  them  and  are  led  by  our 
very  faith  in  the  summary  of  their  life-work,  with  deductions 
therefrom,  and  our  own  convictions,  to  abandon  that  which  is 
hurtful  and  use  that  which  is  helpful. 

*Read  at  45th  Annual  Meeting  of  the  North  Carolina  Medical  Society,  Char- 
lotte,  May  3,  1898. 


,-^  LOTT-MEDDLESOME  GYNAECOLOGY. 

To  say  that  I  never  believed  in  and  never  practiced  certain 
procedures  which  are  largely  the  capital  of  men  who  are  called 
gynaecologists,  would  carry  with  it  little  weight,  but  to  quote 
from  the  life-work  of  the  recognized  masters,  who  in  faithful 
trial  of  such  procedures,  have  "weighed  and  found  wanting," 
must  have  weight  both  in  guiding  our  conscience  and  our  hands. 
Says  T.  A.  Emmet,  so  early  as  1884,  "It  is  believed  that  in  time 
professional  opinion  can  be  influenced  to  abandon  intra-uterine 
medication,  as  one  not  based  upon  sound  views  of  pathology ;  to 
recognize  the  different  forms  and  shades  of  pelvic  inflammation 
outside  of  the  uterus,  now  usually  overlooked,  as  constituting 
the  chief  factor  in  the  diseases  of  woman  ;  and  that  the  exciting 
causes  of  reflex  disturbances  will  be  more  generally  admitted." 
This  same  authority  ^ays:  "We  shill  have  made  great  advance 
it  solving  the  problem  as  to  the  true  pathology  of  many  sup- 
posed uterine  diseases  when  we  seek  the  cause  outside  of  the 
uterine  limits.  For  many  years  I  have  been  convinced  of  the 
truth  that  we  had  been  misled  by  comfounding  cause  and  effect." 
And  again, — "We  look  in  vain  after  death  for  any  evidence  of 
metritis  or  endometritis,  or  for  ulceration  of  the  cervix  as  it  is 
termed,  foi  neither  of  the  conditions,  so  called,  is  inflamma- 
tory." 

Therefore  under  the  old  woman  clature  gynaecologists  were 
justifiable  in  treating  "ulceration  of  the  womb"  with  caustic  ap- 
plications even  though  such  treatment  was  followed  by  "the 
formation  of  cicatrical  tissue  about  the  cervix,"  with  its  accom- 
panying train  of  symptoms  such  as,  "general  nervous  irrita- 
bility and  neuralgia  in  different  parts  of  the  body."  But  under 
the  light  shed  by  the  pathology  of  today  we  know  that  no  such 
ulceration  exists,  and  that  this  condition  of  the  os  and  cervix  is 
almost  always  that  of  everted  tissue,  resulting  from  a  tear  which 
has  occurred  during  child-birth,  and  that  nothing  short  of  re- 
moving such  tissue,  and  uniting  the  freshened  edges  of  a  plastic 
operation,  gives  promise  of  permanent  relief  to  the  patient. 
Under  the  same  head  comes,  incising  the  cervix  for  flexures, — 
forcible  dilatation,  especially  of  the  virgin  womb, — curetting, 
and  vagnial  puncture. 

Incising  the  cervix  is  inflicting  a  wound  which  is  unnecssary, 
unjustifiable,  and  cannot  be  cured,  or,  union  occcuring,  there 
results  a  cicatrix  v;hich,    as  a  local   irritant  multiplies   the   dis- 


LOTT-MEDDLESOME  GYNECOLOGY. 

comforts  of  the  patient,  and  the  dangers,  many  fold.  Lawson 
Tait  in  speaking  of  this  procedure  in  connection  with  the  stem, 
in  the  treatment  of  what  he  terms  "infantile  uterus,"  says: 
"But  looking  back  on  my  experience  of  pelvic  surgery  for  the 
last  fifteen  years,  I  am  entirely  satisfied  that  it  would  have  been 
far  better  for  the  world  if  neither  of  these  proceedings  had  ever 
been  heard  of,  especially  the  use  of  intra-uterine  stems."  And 
Emmet  in  closing  his  chapter  on  treatment  of  flexures  of  the 
uterus, — and  results  of  incision, — disposes  of  the  subject  in  this 
sentence,  "Great  care  can  be  exercised  in  the  proper  selection 
of  cases,  and  in  the  needed  preparatory  treatment,  so  that  com- 
paratively little  damage  may  follow  a  devision  of  the  cervix. 
But  so  much  harm  has  resulted  from  the  operation,  and  so  little 
permanent  benefit, — if  any, — has  been  derived  that  humanity 
would  be  the  gainer  if  public  opinion  in  the  profession  would 
forbid  its  performance.  There  are  a  few  rare  cases  of  congenital 
flexures  of  the  neck  below  the  vaginal  junction,  and  a  smaller 
number  of  permanent  flexures  of  the  body,  where  sometimes 
the  operation  may  be  of  service.  But  these  cases  are  so  rare 
that  I  have  not  divided  a  cervix  uteri  in  eight  or  ten  years,  nor 
in  that  time  have  I  met  with  a  single  instance  where  it  would 
have  been  justifiable  to  perform  the  operation  ;  and  yet  it  is  one 
which  is  being  constantly  performed  in  the  most  irresponsible 
manner  in  ignorace  of  the  cause  of  the  difficulty  and  with  perfect 
indifference  as  to  the  consequences." 

Joseph  Price  says  that  forcible  dilatation  is  a  "Traumatism" 
and  should  never  be  inflicted.  This  is  especially  true  of  the 
virgin  womb,  and  yet  this  procedure,  followed  "under  strictly 
aseptic  methods,"  by  a  "curettage"  is  largely  the  stock  in  trade 
of  numbers  of  routinists  who  are  called  gynaecologists.  Recently 
I  received  a  letter  from  a  young  man  asking  advice  as  to  the 
best  course  to  pursue  in  order  to  prepare  himself  for  the  "routine 
work  in  gynaecology."  Just  think  of  it!  What  will  become  of 
the  work  when  the  workmen  in  flesh,  blood  and  nerves,  with  all 
their  vagaries,  become  routinists?  And  thus  they  are  started 
out,  armed  with  a  stretcher  and  a  scraper  and  fully  licensed  to  in- 
flict irreparable  injury  upon  their  helpless  and  innocent  patients. 

Even  for  the  removal  of  placental  tissue  after  labor  or  abor- 
tion   the   man   who  has  intelligent   fingers   does   not    need    the 


-y6  LOTT-MEDDLESOME  GYNECOLOGY. 

curette,  and  the  man  who  has  not  intelligent  fingers  has  no  busi- 
ness in  the  uterus  at  all. 

Numbers  of  women  conceive  the  idea  that  they  have  "womb 
trouble"  when  in  fact  they  have  a  perfectly  normal  perineum, 
vagina,  uterus,  and  appendages.  Recently  a  husband,  consulted 
me,  much  distressed  because  of  his  wife's  sufferings  from  "fall- 
ing of  the  womb,"  "her  distress  was  great  and  there  was  no 
doubt  about  the  condition,  for  her  family  physician  had  told 
her  so  and  she  had  wo'-n  an  instrument."  Now  the  odds  were 
much  against  me  when  upon  examining  this  woman  I  found  the 
reproductive  organs  in  no  abnormal  position  or  condition  at  all, 
— but  just  where  the  urethra  entered  the  bladder  an  exquisitely 
sensative  point.  An  examination  of  the  urine,  and  finding  it 
loaded  with  pus,  confirmed  the  diagnosis  of  vesical  catarrh,  and 
forty  grains  of  boracic  acid  daily,  (ten  grains,  in  capsules,  after 
meals  and  at  bed  time) — in  spite  of  her  utter  disbelief  in  my 
opinion  and  treatment,  after  a  very  few  days,  gave  entire  re- 
lief. 

It  is  much  harder  work,  and  requires  closer  observation,  to 
be  able  to  recognize  a  normal  pelvis,  and  pelvic  organs  which 
are  not  incompatible  with  the  health  and  comfort  of  the  patient, 
than  it  is  to  find  a  misplaced  uterus,  or  other  pathologic  condi- 
tions when  existing, — and  in  many  of  these  cases  it  i.i  a  much 
easier  task  to  gravely  touch  the  cervical  canal  with  a  sound,  and 
swab  the  vagina  with  cotton  twice  or  thrice  weekly, — in  short 
t  )  "give  them  treatment"(?)  than  it  is  to  correct  the  mental 
error  and  convince  them  that  they  need  no  tinkering  at  all. 

Vaginal  puncture,  for  suppurating  inflammation  of  pelvic 
organs,  is  a  stab  in  the  dark^  and  may  be  ascribed  rather  to  timi- 
dity, than  to  a  thorough  investigation  of  results.  That  numbers 
of  abdominal  sections  are  done  unnecessarily,  I  fully  gree,  but 
it  is  not  such  we  are  considering, — we  cannot  be  responsible  for 
the  work  of  fanatics, — it  is  those  in  which  there  is  pus  in  the 
pelvis  which  should  be  let  out;  and  that  its  evacuation  through 
the  vaginal  vault  is  simple  and  easy  of  execution,  neither  guar- 
antees the  future  relief  and  comfort  of  the  patient,  nor  estab- 
lishes the  wisdom  c»f  the  procedure. 

The  cases  in  which  the  vagina  affords  a  favorable  field  for 
work  are  few,  and  cases  in  which  it  is  possible  to  determine  be- 


LOTT-MEDDLESOME  GYN^.COI.CGY.  --- 

forehand  the  exact  pathologic  conditions,  or  position  of  the  pel- 
vic contents,  and  just  what  should  be  done,  are  none  at  all.  It 
is  just  in  this  particular  that  the  gynaecologist  differs  from  that 
of  the  gener  d  surgeon.  In  fact  the  very  years  of  ripe  experience 
which  best  fit  the  general  surgeon  for  the  noble  work  in  his  broad 
field, — unfit  him  for  successful  work  in  abdominal  and  plastic 
surgery.  There  should  be  no  rivalry  between  the  two,  each  has 
in  view  the  prolonging  of  human  life  and  the  relief  of  human 
suft'ering,  and  to  go  hand  in  hand  gives  strength  to  both.  You 
do  not  hear  of  rivalry  between  the  carpenter  and  the  cabinet 
maker, — the  world  and  the  work  are  large  enough  for  both,  nor 
would  you  entrust  a  piece  of  work  which  you  knew  came  within 
the  province  of  one  to  the  other. 

A  stab  through  the  vagina  may,  by  a  happy  chance,  give  vent 
to  pus  and  j-^^^'/zm^^/y  relieve  the  patient,  but,  with  the  lights  of 
today  this  fact  does  not  relieve  the  hand  that  inflicts  it  of  re- 
sponsibility in  the  matter;  nor  does  it  save  the  patient  from  suffer- 
ing which  follows  incomplete  work,  and  the  extensive  bowel 
adhesions  and  lesions  ''with  universal  fixation  of  tubes  and 
ovaries"  (Price)  which  are  found  when  she  finally  comes  to  the 
hands  of  the  surgeon  who  is  equipped  to  do  clean ^  thorough  work. 

DISCUSSION. 

Br.  McMullan: — I  was  deeply  interested  in  the  iconoclastic 
paper  of  my  worthy  triend  and  brother.  In  chaste  and  beautiful 
language,  he  told  us  how  not  to  do  it,  and  I  listened  with  the 
gravest  attention  possible  to  find  out  from  him  how  to  do  it. 
How  does  he  correct  these  troubles  that  come  to  us  in  our  prac- 
tice from  day  to  day  in  our  female  patients.  When  I  have  a 
patient  come  to  me  suffering  from  all  symptoms  of  pelvic  disease, 
and  on  making  an  examination  find  the  uterus  suffering  from 
involution,  misplaced  and  discharging  a  glairy  substance  very 
much  like  the  dysenteric  discharge  we  have  in  bowel  trouble, 
there  is  a  way  which  I  have  used  that  has  always  given  me  good 
results,  and  though  the  treatment  is  otten  tedious,  if  presisted 
in,  I  generally  get  there.  I  believe  in  tamponing  with  the  boro- 
glyceride  tamponade,  and  in  proper  applications  to  the  interior 
of  the  womb,  the  endometrium,  and  after  a  while  when  neces- 
sary, lifting  of  that  uterus  on  a  well  fitting  retroversion  pessary, 
when  by  so  doing  we  would  confer  a  benefit  upon  the  patient, 
and  in  a  great  many  instances  cure  the  disease.  Again,  when 
he  mentions  vaginae  atresia  cervici,  he  tells  us  we  must  not  cut, 
he  tells  us  we  mast  not  dilate,  but  he  fails  to  tell  us  how  we 
shall  relieve  the  excessive  and  excruciating  suffering  that  many 


,«8  LOTT-I\IEDDLESOME  GYNECOLOGY. 

of  these  dear  ladies  suffer.  As  long  as  any  medicinal  agent  can 
be  found  to  relieve  them,  it  is  improper  to  meddle,  but  when 
month  after  month  I  have  exhausted  every  available  resource  and 
still  find  the  patient  doubling  with  excruciating  pain  and 
upon  the  verge  of  convulsions,  what  am  I  to  do?  I  would 
like  to  ask  the  gentleman  when  he  has  atresia  of  the  urethra,  does 
he  quietly  sit  down  and  fold  his  hands  and  use  no  means  to  dilate 
that  stricture?  I  would  get  my  coarser  curette  or  sound  and 
try  to  establish  the  normal  caliber  of  the  canal.  I  see  no  earthly 
reason  why  we  should  not  attempt  to  establish  the  normal  open- 
ing in  the  cervix  uteri  and  I  have  conferred  great  benefit  by 
gradual  and  careful  dilatation  from  time  to  time.  In  the  mean- 
time, if  the  virgin  should  become  married,  that  solves  the  whole 
riddle.  I  would  be  very  glad  if  the  doctor  would  tell  me  how 
to  get  over  these  difficult  points  without  doing  some  of  this 
which  he  characterizes  as  "meddlesome  gynecology."  It  is  not  a 
pleasant  thing  to  me  to  have  to  do  it,  and  I  take  it  up  with  re- 
luctance when  I  find  it  has  to  be  done. 

Dr.  Sikes: — There  is  one  po'nt  in  the  doctor's  paper  I  noticed, 
and  that  is  in  regard  to  the  educ-.ted  finger.  My  experience 
has  been  different  from  his  as  regards  the  educated  finger.  It 
is  one  of  the  most  useful  instruments,  especially  in  cases  of  early 
abortion.  Some  of  the  most  troublesome  cases  we  have  are  exces- 
sive hemorrhage  from  early  abortions  before  the  cervix  is  not 
sufficiently  dilated  to  pass  out  the  product  of  conception.  Some- 
times life  is  very  much  endangered,  and  instead  of  waiting  until 
the  cervix  is  dilated  enough  for  the  product  of  conception  to 
pass  away,  as  soon  as  we  find  that  abortion  is  inevitable,  with  a 
little,  long-handled  dressing  forceps  introduced  at  the  end  of  a 
skilled  finger — a  skilled  finger  is  a  great  acquisition  to  the  prac- 
tical physician — we  can  remove  this  little  product  of  conception 
and  it  frequently  puts  the  woman  instantly  at  rest,  arrests  the 
hemorrhage,  and  in  that  way  results  in  a  most  excellent  result. 
I  have  in  mind  right  now  a  case  I  had  only  a  few  weeks  ago  in 
which  death  seemed  quite  imminent  from  loss  of  blood,  and  in 
five  minutes  after  I  entered  the  house  and  removed  the  clot, 
there  was  not  any  more  hemorrhage  and  the  woman   recovered. 

Dr.  McGuire: — It  gives  me  great  pleasure  to  meet  you  all  in 
this  session.  I  had  intended  to  come  here  as  a  listener,  and  not 
to  have  anything  to  say.  I  have  always  been  afraid  of  the  North 
Carolina  Medical  Society,  because  I  never  met  a  North  Caroli- 
nian who  could  not  make  a  speech.  When  I  was  coming  down 
here,  Dr.  Edwards,  editor  of  the  Virginia  Medical  Semi-monthly, 
said  to  me,  "McGuire,  don't  you  say  anything  down  there. 
Those  North  Carolinians  always  make  speeches,  and  they'll  beat 
you  all  to  pieces."  So  I  determined  to  keep  quiet  until  my  friend 
brought  me  before  the  Society. 

In  regard  to  the  discussion  of  the  paper  of  Dr.  Lott,  I  cannot 


LOTT-MEDDLESOME  GYNAECOLOGY 

379 
agree  entirely  with  the  doctor  in  regard  to  the  operation  of  dila- 
tation and  currettement.  I  am  sure  I  have  seen  dilatation  re- 
peatedly do  good,  and  I  do  not  hesitate  to  resort  to  it  whenever 
it  is  demanded,  either  for  constricted  cervix  or  anteflexed  uterus 
so  that  the  circulation  and  discharge  are  interfered  with,  and  if  it 
is  kept  up  for  a  sufficient  length  of  time,  will  produce  an  irritable 
condition  of  the  nerves  leading  to  the  endometrium,  and  in  a 
little  while  you  will  have,  besides  the  pain  incident  to  menstru- 
ation, that  incident  to  nervous  hyperaesthesia.  I  have  seen  these 
cases  of  dysmenorrhoea  relieved  easily  and  for  a  long  time  from 
the  simple  operation  of  dilatation.  It  is  a  perfectly  safe  opera- 
tion if  done  in  a  clean  way  and  there  is  no  danger  at  all.  Of 
course  I  would  not  dilate  if  there  was  intra-pelvic  trouble  which 
produced  the  painful  menstruation. 

Curettement  is  another  valuable  operation.  I  have  the  highest 
opinion  of  Dr.  Price.  I  know  him  personally  and  I  have  seen 
him  operate  a  great  many  times.  He  is  not  very  fond  of  that 
operation,  but  he  is  very  often  a  little  extreme  in  his  views.  It 
is  an  operation  accepted  by  the  entire  profession  almost,  with 
the  exception  of  Dr.  Price,  all  over  this  country,  the  operation 
of  curetting  and  dilatation.  I  know  of  no  simple  operation  which 
will  so  speedily  give  relief  »s  these  two,  if  done  under  the  proper 
aseptic  conditions.  Of  course  we  sometimes  have  cases  in  which 
remedies  are  useful  to  the  endometrium,  but  I  am  not  very  much 
of  a  believer  in  intra-unterine  medication.  It  ought  to  be  done 
under  the  most  perfect  aseptic  conditions,  the  same  as  a  surgical 
operation,  and  in  a  great  many  cases,  instead  of  the  prolonged 
use  of  Churchill's  Tincture  of  Iodine,  the  endometrium  could 
be  relieved  much  more  quickly  by  the  operation  of  curetting. 
Local  application  to  the  vagina  I  do  believe  in,  and  I  have  seen 
it  do  good.  After  pelvic  inflammation  I  frequently  resort  to  a 
species,  you  may  call  it,  of  uterine  tinkering  to  reduce  the  con- 
gestion. 

Dr.  Royster: — I  am  very  glad  that  the  discussion  of  Dr.  Lott's 
paper  was  called  up  before  it  was  too  late,  for  I  am  sure  it  is 
worthy  of  discussion  by  the  Society.  I  came  in  late  and  there- 
fore heard  only  the  latter  part  of  his  paper,  the  part  which  per- 
haps interested  me  most,  and  on  which  I  will  try  to  make  a  few 
remarks,  vaginal  versus  abdominal  section  for  pus  accumulation 
in  the  pelvis.  It  has  been  discussed  and  rediscussed  for  the  past 
fifteen  or  twenty  years,  and  professional  opinion  is  constantly 
changing  and  rechanging.  The  French  school  of  vaginal  sec- 
tionists  for  a  long  time  held  sway,  perhaps  for  the  last  three  or 
four  years,  when  opinion  seems  to  be  switchine  the  other  way, 
certainly  at  least  in  this  country.  My  personal  opinion  in  regard 
to  this  matter  will  not  go  very  far,  because  my  experience  has 
been  small,  but  the  experience  I  have  had  justifies  me  in  assert- 
ing a  very  conservative  opinion  on  the  question.     And  that  is. 


-gQ  LOTT-MEDDLESOME  GYNAECOLOGY. 

that  every  case  is  a  luvv  unto  itseif  in  this  regard.  While  in  most 
cases  treatment  by  the  abdominal  route  is  the  cleanest  and 
nearest  way,  there  are  other  cases  in  which  the  vaginal  puncture 
is  safest.  I  should  hate  to  attack  an  accumulation  of  pus  in  the 
pelvis  which  was  low  down,  seemingly  walled  off,  through  the 
abdominal  passage-way,  but  should  certainly  not  hesitate  to 
open  it  through  the  vagina  and  give  the  woman  instant  and 
temporary  relief.  If  there  were  any  secondary  operation  to  be 
done,  I  should  feel  more  like  attacking  it  through  the  abdomen. 
I  have  also  done  two  vaginal  sections  for  extra-uterine  preg- 
nancy, in  the  latter  stages  after  the  cessation  of  hemorrhage, 
and  a  case  which  presented  true  pelvic  haematocele,  walled  off, 
in  which  the  patient's  condition  was  favorable.  I  have  done  two 
like  that  Dr.  Kelly  described,  making  an  incision  in  the  median 
line  and  following  that  with  the  fingers  or  scissors  and  removing 
the  clots,  washing  with  a  salt  solution,  and  also  cleaning  out  the 
products  of  conception,  if  any  remained.  Both^of  my  cases  re- 
sulted in  perfect  cures.  The  last  was  over  a  year  and  a  half  ago, 
with  absolutely  no  return  of  the  pelvic  symptoms.  She  has  since 
become  pregnant,  and  is  now  six  months  in  that  state.  I  am  not 
a  rabid  abdominal  sectionist,  nor  am  I  wedded  to  vaginal  sec- 
tions in  all  cases,  but  I  hold  the  conservative  view  that  I  always 
treat  every  case  by  itself  and  of  itself. 

In  regard  to  curetting,  I  must  do  myself  the  honor  to  agree 
with  Dr.  McGuire  I  know  of  no  simple  operation  in  which  the 
results  are  so  satisfactory  as  in  the  simple  operation  of  curettage 
of  the  uterus,  either  from  troubles  arising  from  bad  develop- 
ment or  from  inflammatory  diseases  of  the  uterus.  It  must  be 
done  with  the  precautions  which  we  would  undertake  in  doing 
a  perfect  abdominal  section,  aseptic  throughout.  The  different 
methods  of  doing  curetting  matter  little,  because  if  done 
promptly,  any  way  is  always  good.  In  the  matter  of  longer 
treatment,  gynecological  treatment,  I  have  given  that  up  en- 
tirely except  in  the  matter  of  preparing  for  subsequent  opera- 
tions. Douches,  tampons,  boroglyceride  treatments  and  appli- 
cations to  the  vagina  all  do  good,  but  if  there  is  any  deep-lying 
organic  trouble,  nothing  but  a  surgical  operation  will  relieve.  I 
hope  that  this  question  of  vaginal  versus  abdominal  section  for 
pus  accumulations  by  inflammatory  pelvic  diseases  will  receive 
some  discussion,  because  I  am  sure  it  is  of  interest  to  all  of  us, 
and  it  has  never  been  fully  discussed  in  the  State. 

Dr.  Loft: — I  would  like  to  have  a  moment  in  order  to  thank 
these  gentlemen  most  heartily  for  the  discussion.  My  greatest 
hope  in  writing  the  paper  was  to  bring  up  the  discussion  and 
throw  light  upon  this  subject. 


REPORT    OF  CHAIRMAN   OF  THE   SECTION  ON    OB- 
STETRICS.* 

By  W.  G.  Stafford,  M.  D.,  Burlington,  N.  C. 


FROM  one  hundred  blanks  sent  to  representative  members  of 
the  North  Carolina  State  Medical  Society,  I  have  received 
fourteen  responses.  These  reports  contain  a  summary  ot 
important  cases  treated  during  the  year  ending  April  the  15th 
1898.  It  is  to  be  regretted  that  so  few  reports  were  made.  Still, 
there  are  enough  to  serve  to  illustrate  the  methods  obtaining 
within  the  borders  of  our  State  and  the  success  attending  them: 

One  case  of  caesarean  section  for  extra  uterine  gestation  is  re- 
ported by  Dr.  J.  B.  Powers.  Operation  performed  by  Dr.  Hu- 
bert A.  Royster,  Dr.  Powers  being  disabled  by  a  carbuncle. 
The  operation  saved  the  life  of  the  mother.    Both  children  died. 

Dr.  W.  O.  Spencer  reports  two  cases  of  placenta  proevia,  one 
central,  the  other  marginal;  four  cases  of  puerperal  eclampsia; 
three  cases  of  forceps  at  pelvic  brim  ;  four  cases  of  forceps  in 
pelvis;  three  cases  of  version  in  utero;  three  cases  curetted 
after  labor;  and  nine  after  abortion.  No  case  of  death  of  mother; 
but  three  cases  of  death  of  child. 

Dr.  Henry  T.  Bahnson  reports  two  cases  of  forceps  at  brim  of 
pelvis,  and  five  cases  of  forceps  in  pelvis.  He  reports  one  case 
of  septic  trouble,  cause  unknown,  resulting  in  death  of  mother. 
No  death  of  child. 

Dr.  J.  Howell  Way  reports  one  case  of  forceps  at  brim  of 
pelvis;  two  cases  of  forceps  In  pelvis;  four  cases  curetted  after 
abortion — prompt  recovery  in  each  case;  two  cases  of  version 
in  utero,  one  of  which  was  a  pseudocephalus,  classification  after 
Geoffery  St.  Hilaire,  and  was  still-born.  One  case  of  forceps 
in  pelvis  was  in  consultation,  after  ergot  had  been  freely  ex- 
hibited.     No  case  of  death  of  mother. 

Dr.  I.  W.  Faison  reports  a  case  of  puerperal  eclampsia, 
with  shoulder  and  arm  presenting,  in  which  craniotomy  was 
done  and  forceps  applied  in  utero.      Mother  recovered. 

Dr.  E.  F.  Strickland  reports  one  case  of  forceps  at  brim,  three 

cases  of  forceps  in  pelvis,  one  case  of  version  for  shoulder  pre- 

*Read  at  45th  Annual  Meeting  of  the  North  Carolina  Medical  Society,  Char- 
lotte, May  3,  1898. 


^g2  STAFFORD-REPORT  ON  OBSTETRICS'. 

sentation,  one  case  of  sep-tic  trouble  treated  by  curette,  due  to^ 
infection  by  retained  membranes.  He  also  reported  an  inter- 
esting case  of  twins  of  unequal  development,  and  one  case  of 
triplets.  These  will  be  elat>orately  reported  by  Dr.  S.  in  his- 
paper. 

Dr.  W.  H.  H.  Cobb  reports  six.  cases  of  forceps  in  pelvis,  one 
case  of  version,  two  cas-es  curetted  after  labor  and  four  after 
abortion.  He  reports  one  case  of  sepsis  due  to  t3'^phoid  infec- 
tion, and  two  cases  of  post  partum  hoemorrhage.  No  death  of 
mother  or  of  child. 

Dr.  Geo.  W.  Long  reports  two  cases  of  placenta  previa,  one 
seen  in  consultation.  Both  were  treated  by  podalic  version 
and  delivery.  Both  mothers  were  saved,  botk  children  lost, 
being  at  7th  month  in  utero. 

Dr.  W.  P.  Ivey  reports  one  case  of  shoulder  presentation,, 
which  he  treated  by  version.  Mother  and  child  saved.  He  also 
reports  one  case  of  septic  infection,  and  one  of  post  partum 
eclampsia.      No  death  of  mother  or  child. 

Dr.  Chas.  J.  O.  H.  Laughinghouse  reports  eight  cases  of 
forceps  applied  in  pelvis,  three  cases  of  version,  one  case 
curetted  after  labor,  and  six  cases  after  abortion.  No  case  of 
death  of  mother  or  child. 

Dr.  Thomas  M.  Jordan  reports  a  case  of  embryotomy  on  ac- 
count of  deformed  pelvis.  Septic  trouble  developed  followed 
by  the  death  of  the  patient. 

Dr.  C.  N.  Roberson  reports  two  cases  oi post  partum  haemor- 
rhage.     Patients  recovered. 

Dr.  W.  P.  Beall  reports  seven  cases  of  forceps  applied  in  pel- 
vis; one  case  oi placenta praevia,  treated  by  version  and  delivery. 
Both  mother  and  child  saved.  He  reports  four  cases  curetted 
after  abortion,  two  cases  of  which  were  septic.  No  case  of  death 
resulted. 

Dr.  Henry  H.  Dodson  reports  two  cases  of  forceps  applied  in 
pelvis,  and  three  cases  curetted  after  abortion.  No  death  of 
mother  or  child. 

summary: 
1  Caesarean  Section, 
7  Cases  forceps  at  brim, 
37       "  "         in  pelvis, 

12       "       version, 


;STAFFORD— REPORT  ON  OBSTETRICS. 


383 


7       ' 
32       ' 

'      curetted,  after  labor, 
'         "            "         abortion,, 

1       ' 

4       ' 
6       ' 
2 

•5       ' 

*        embryotomy, 

'       post  partum  hsemorrhage, 

'      eclampsia, 

'       death  of  mother, 

'        "      "     infant. 

To  my  mind,  these  figures  indicate  great  care  and  skill  exer- 
cised both  in  opera' ing  and  in  the  after  treatment.  The  cases 
of  death  of  mothers  should  be  eliminated  from  the  list,  as  they 
were  beyond  control  of  the  physician  before  he  was  called. 

It  is  gratifying  to  note  that  there  is  less  disposition  than  for- 
merly to  meddle  with  normal  cases. 

For  quite  a  while  it  was  thought  that,  even  in  normal  cases, 
douches  should  be  given  as  a  routine  treatment.  It  is  now 
fairly  conceded  that,  under  ordinary  environment,  they  are  of 
•doubtful  benefit  if  not  positively  harmful. 

The  use  of  the  sharp  curette  to  precede  the  douche,  in  cases 
with  slight  rise  of  temperature,  finds  but  few  advocates  noW; 
not  many  being  willing  to  inflict  such  an  extensive  area  of  trau- 
matism and  lay  open  so  many  avenues  to  infection  by  cutting 
off  terminal  recesses  which  before,  were  blocked  up  by  leuco- 
cytes. 

If  the  uterus  be  properly  cleaned  out  at  the  time  of  secundine 
expulsion,  which  nature  will  effect  in  most  cases,  there  will  be 
little  use  for  any  curette  during  the  continuance  of  the  puerpe- 
ral state.  If,  however,  shreds  of  membrane,  broken-down  pla- 
centa etc.,  have  been  retained,  there  is  no  objection  to  the  dull 
instrument,  using  it  as  a  manipulative  adjunct  rather  than  as  a 
surgical  instrument.  The  sharp  instrument  here  is  capable  of 
doing  no  good  beyond  what  may  be  readily  accomplished  by  its 
dull  prototype,  while  it  is  infinitely  more  potent  for  harm. 

The  hot  saline  or  antiseptic  douche  should  be  applied  to  the 
interior  of  the  uterus  after  any  such  curettement.  My  prefer- 
ence is  for  the  saline.  Instead  of  intra-uterine  drainage  my 
preference  is  for  tampons  of  absorbent  wool  saturated  with  a 
5  per  cent  solution  of  boroglyceride,  previously  sterilized,  of 
course.  This  favors  rapid  exosmosis,  while  the  canal  of  the 
cervix  is  patent  and  will  suffice  for  drainage.  In  the  meantime 
the   temperature,    strength,    and  ability  to  appropriate  nourish- 


,8  -  STAFFORD-REPORT  ON  OBSTETRICS. 

ment,  will  give  the  index  of  the  proper  constitutional  treatment. 

Those  of  us  who  have  practiced  in  the  country  have  often 
been  amused  and  perhaps,  disgusted  at  some  superstitions  wh:ch, 
at  first  thought,  seem  to  have  their  origin  in  an  aversion  to 
cleanliness  and  decency :  such,  for  instance,  as  that  the  patient 
must  not  have  a  bath,  and  that  the  ashes  must  not  be  removed 
from  the  fireplace  under  the  ninth  day,  etc.  Still,  it  was  proba- 
bly the  same  superstition  that  caused  those  ignorant  nurses  to 
scorch  and  scrape  all  cloths  that  were  to  come  in  contact  with 
the  genitalia  of  the  patient,  burn  the  secundines,  and  give  to 
the  baby,  for  colic,  a  weak  solution  of  creosote  manufactured 
from  the  soot  of  the  chimney  by  infusion. 

Perhaps  those  poor  nurses,  unable  to  make  microscopic  or  to 
analyze  macroscopic  observations,  noticed  that  puerperal  women 
did  the  best  when  interferred  with  the  least,  and  that,  with  their 
environment,  interference  was  apt  to  end  in  trouble,  though 
they  know  not  why  it  came — as  from  germ-life,  or  that  it  came 
from  without;  or,  yet,  that  nature  provided  in  the  products  of 
involution  a  material  inhibitory  of  these  agencies. 

While  the  poor  woman  in  child  bed  could  keep  a  v»/hole  skin 
between  herself  and  the  army  of  microbes,  though  her  bed  might 
be  full  of  them,  so  to  speak,  she  was  "clad  in  mail  of  proof," 
thanks  to  beneficient  Providence  who  decreed  the  lochia  an 
obstacle  to  the  development  of  dangerous  germs,  as  well  as  that 
the  uterine  ciliated  epithelium  should  be  a  bar  to  their  ascent. 

The  lesson  we  learn  from  this  wonderful  immunity  is,  unless 
in  the  face  of  strong  reasons  to  the  contrary,  not  to  meddle 
with  a  puerperal  woman,  except  to  keep  herself  and  her  sur- 
roundings clean. 

In  this  connection,  I  am  lead  to  remark  that  there  is  much 
yet  te  be  desired  in  the  way  of  prophylaxis  against  the  neces- 
sity for  operative  procedure,  especially  in  cases  of  contracted 
pelvis.  That  is,  to  prevent  the  contracted  pelvis.  Dress  reform, 
within  certain  limits,  will  do  much  to  correct;  but  other  factors 
operate  to  produce  the  conditions  besides  ill-fitting  dress.  In- 
sufficient and  improper  nourishment ;  constrained  positions  while 
at  work  or  in  school;  scant  exercise;  want  of  light  and  fresh  air 
— in  a  word,  want  of  proper  hygienic  conditions — are  the  ele- 
ments against  which  we  have  to  do  battle. 


STAFFORD-REPORT  ON  OBSTETRICS.  .^gr 

In  contracted  pelves,  we  have  the  origin  of  a  ghastly  train  of 
•evils  which  neither  forceps,  caesarean  section,  craniotomy  nor 
•symphysiotomy  have  served  to  forestall.  At  this  door  we  may 
lay  much  of  all  that  is  implied  in  the  general  term  of  invalidism 
in  woman.  To  particularize,  we  will  say  that  much  of  lacerated 
■cervix  and  perinaeum,  of  loss  of  tone  by  over  distention,  of 
pressure  effects  upon  nerves,  and  of  sepsis,  are  justly  to  be  laid 
to  the  charge  of  their  condition. 

For  the  prevention  and  control  oi  post  par  trim  haemorrhage 
and  combatting  its  effects,  there  seems  little  to  be  desired, 
■either  in  remedies  or  in  methods  of  application;  more  especially 
since  the  introduction  of  normal  saline  infusion.  This  can  be 
introduced  into  the  circulation  by  injection  into  a  vein,  into  the 
•cellular  tissue,  or  into  the  rectum,  giving  all  the  advantages  of 
transfusion  of  blood  without  its  disadvantages. 

The  death  of  a  nobie  victim  of  this  condition,  in  the  early 
part  of  the  present  century,  pravoked  this  comment  from  the 
most  gifted  subject: 

"Scion  of  Chiefs  and  Monarchs,  wliere  avt  thou? 

Fond  hope  of  many  nations,  art  thou  dead? 

Could  not  the  grave  forget  thee  and  lay  low, 

Some  less  majestic,  less  beloved  head? 

In  the  sad  midnight,  while  thy  heart  still  bled, 

The  mother  of  a  monarch,  o'er  thy  boy, 

Death  hushed  that  pang  forever:  with  thee  fled. 

The  present  happines  and  promised  joy, 

Which  fill'd  the  imperial  isles  so  full  it  seem'd  to  cloy! 

Peasants  bring  foi'th  in  safety — can  it  be, 

O  thou  that  wert  so  happy,  so  adored! 

Those  who  weep  not  for  kings  shall  weep  for  thee, 

And  freedoms'  heart,  grown  heavy  cease  to  hoard 

Her  many  gii'efs  for  one;  for  she  had  pour'd, 

Her  orisons  for  thee,  and  o'er  thy  head 

Beheld  her  Iris. — Thou,  too,  lonely  lord, 

And  desolate  Consort — vainly  wert  thou  wed, 

The  husband  of  a  year!  the  father  of  the  dead!" 

We  rejoice  that  the  lives  of  so  many  uncrowned  years  are  now 
saved  under  like  conditions ;  the  causes  that  prcduce  post  partum 
hoemorrhage,  and  the  means  to  control  and  correct  its  effects 
being  better  understood. 


THREE  INTERESTING  CASES  OF  OBSTETRICS.' 
By  E.  F.  Strickland,  M.  D.,  Bethania,  N.  C. 


1  DESIRE  to  express  my  appreciation  and  to  return  thanks  to 
Dr.  Stafford,  Chairman  of  Section  on  Obstetrics,  for  his 
evident  confidence  and  kindness  in  selecting  me  to  write 
one  of  the  papers  to  be  presented  under  his  section.  I  bespeak 
a  rupture  of  that  confidence  ere  this  task  is  done  but  pray  for  a 
continuance  of  the  friendship.  The  art  of  midwifery  in  general 
is,  to  the  average  practitioner,  perhaps,  the  most  interesting 
branch  of  our  profession.  The  young  doctor  is  filled  with 
thoughts  sublime  and  feels  himself  a  hero  when  his  first  case  of 
natural  labor  is  concluded.  The  old  practitioner  recalls  with 
pardonable  pride  the  many  obstacles  he  has  met  and  overcome 
in  contending  with  the  emergencies  of  unnatural  labor  that 
threatened  the  life  of  either  mother  or  child,  or  both,  and 
the  breaking  up  forever  of  the  once  tranquil  and  happy  home. 
Childbirth  should  always  be  regarded  as  one  of  the  most  critical 
ordeals  in  human  life,  and  we  shudder  as  we  think  of  the  irre- 
sponsible, ignorant  and  untutored  midwife  as  she  stalks  forth, 
filled  with  conceit  and  superstition,  to  meets  condition  that  tax 
the  energy  and  exhaust  the  resources  of  the  most  skilled  in  the 
art.  But  the  Chairman  has  designated  that  my  paper  consist 
of  a  report  of  the  following  "Thiee  interesting  cases  of  obstet- 
rics" that  have  been  recently  added  to  my  experience. 

ist.  On  September  3rd  1897,  I  was  called  to  see  Mrs.  P.  who 
was  in  labor  and  who  shortly  after  my  arrival  was  delivered  of 
twins.  One  child  was  stout  and  well  developed;  the  other  was 
quite  small,  weak  and  immature  and  lived  but  a  few  hours. 
The  mother  gave  the  following  history:  Nine  months  ago  she 
menstruated  as  usual;  a  month  later  she  imagined  herself  preg- 
nant, as  menstruation  did  not  appear  and  "morning  sickness" 
commenced,  as  in  former  pregnancies;  still  a  month  later,  i.  e., 
seven  months  prior  to  confinement,  menstruation  reappeared  but 
has  not  since  returned. 

She  knew  not  from  which  date  to  calculate  the  period   of  her 

delivery.      From  the  appearance  of  the  twins,    the   presence   of 

*Read  at  45th  Annual  Meeting  of  the  North  Carolina  Medical  Society,  Char- 
lotte, May  3,  1898. 


STRICKLAND-THREE  INTERESTING  CASES  OF  OBSTETRICS.         ^3- 

two  placentae  and  the  history,  I  began  to  theorize  as  follows: 
might  not  an  independent  conception  have  resulted  from  ovula- 
tion at  the  time  of  menstruation  when  the  woman  was  already 
two  month's  pregnant,  and  thus  an  example  of  superfoetation? 
This  case  is  all  the  more  interesting  because  of  the  menstru- 
ation, as  the  coincidence  of  menstruation  and  superfoetation  in 
early  pregnancy  is  very  rare — only  the  fewest  member  being  on 
record. 

2nd.  On  December  15th,  1897,  I  was  called  a  distance  of  six 
or  eight  miles  to  the  country  to  see  Mrs.  S.  who  was  having 
alarming  uterine  hemorrhage.  On  my  arrival,  from  appear- 
ances and  information,  I  judged  the  loss  of  blood  to  be  at  least 
one-half  gallon.  I  elicited  the  following  history :  On  September 
3rd,  1897,  unattended  by  medical  assistance,  she  had  a  miscar- 
riage relieving  her  of  wiiat  was  supposed  to  be  a  six  months' 
child.  All  seemed  to  go  well  and  there  was  not  the  slightest 
anticipation  of  trouble  ahead  until  more  than  two  months  later. 
I  put  the  patient  under  the  influence  of  a  general  anaesthetic 
(chloroform)  and  with  considerable  difficulty  dilated  the  uterus 
and  removed  a  mass  of  very  offensive  decomposing  placenta 
half  the  size  of  the  hand.  I  curetted  the  whole  of  the  interior 
of  the  uterus  and  gave  antiseptic  intra-uterine  injections  con- 
sisting of  bichloride  of  murcury,  i  to  2,000.  She  was  put  on 
iron,  quinine  and  strychnia  together  with  a  generous  nutritious 
diet  and  confined  to  bed  for  ten  days.  There  was  not  the 
sliglitest  elevation  ot  temperature  and  no  more  hemorrhage,  but 
a  rapid  return  to  her  characteristic  excellent  state  of  health. 

The  notable  features  of  this  case  are:  ist,  that  the  constitu- 
tional vigor  of  the  patient  was  so  great  that  the  poisonous  pro- 
ducts of  decomposition  in  utero  were  cast  off  without  making 
the  least  septic  impression ;  2nd,  that  she  should  have  gone  so 
long,  seventy  odd  days,  without  the  least  vaginal  discharge, 
purulent  or  otherwise;  3rd,  that  when  the  crisis  did  come  it  was 
so  grave  and  yet  her  recovery  so  rapid  and  complete.  She  is 
an  intelligent,  honest  aud  obedient  patient  and  I  feel  grateful 
to  Providence  for  her  almost  miraculous  escape. 

3rd.  On  January  31st,  1898,  I  was  summoned  to  see 
Mrs.  W.  who  was  reported  six  months  pregnant  and  'threat- 
ened with  miscarriage."     Patient  stated   that   she  had  slipped 


„gg.  BLOUNT— THE  CHEMISTRY  OF  THE  STOMACH. 

and  fallen  from  door  slep  three  days  before  which  gave  her  body 
a  considerable  jar  and  badly  sprained  her  ankle.  She  felt  no- 
inconvenience  afterwards,  except  from  affected  ankle,  until  on 
the  31  St  when  suddenly  there  was  a  large  discharge  of  amniotic 
fluid  and  hence  my  presence  requested.  In  the  next  six  hours 
I  delivered  my  patient  of  triplets,  all  girls  and  well  developed^ 
and  I  might  add  equally  well  developed  for  they  were  as  nearly 
alike  as  three  peas  in  a  pod.  They  all  died  within  twelve  hours 
after  birth.  The  mother's  recovery  was  uneventful  and  as  rapid 
and  complete  as  in  former  single  births.  The  frequency  of 
multiple  births  varies  remarkably  in  different  races  and  coun- 
tries, depending  perhaps  upon  the  general  fecundity  of  the  in- 
habitants. Taking  the  average  of  a  large  number  of  cases  col- 
lected by  different  authors  in  various  countries  we  find  that  triplet 
pregnancies  occur  about  once  ir  7,679  labors.  The  causes  of 
multiple  pregnances  are:  ist,  the  materuation  and  rupture  of 
more  than  one  Graffian  follicle  at  or  near  the  same  time;  2nd,, 
the  casting  ofi  from  a  single  Graffian  follicle  of  more  than  one 
ovule;  3rd,  the  casting  off  from  a  single  Graffian  follicle  of  a 
single  ovule  containing  more  than  one  germ.  It  is  credited  by 
good  authority  that  heredity  plays  an  important  part  in  multiple 
births.  In  the  case  cited,  the  father  on  hearing  the  mother  give 
negative  answers  to  my  inquiry  concerning  multiple  births  in 
her  family,  promptly  named  several  cases  of  twin  births  that 
had  occurred  in  his  own  family  which  statement  was  verified  by 
his  mother.  But  here  I  stick  the  "safety-pin,"  and  thank  you 
all  very  much  for  your  attention. 


THE  CHEMISTRY  OF  THE  STOMACH.* 
By  J.  G.  Blount,  M.  D.,  Washington,  N.  C. 


IN    this  rapidly  advancing  age  where  the  strain  of  business,  ex- 
haustion of  pleasure,  sensual  excesses  in  eating  or  drink- 
ing, or  in  this  country  especially,  by  the  manifold  errors 
committed   in   the   preparation   and    consumption   of   food   and 
the  utter  disregard  of  all  hygienic  rules  in  their  habits  of  living, 

*Read  at  45th  Annual  Meeting  of  the  North  Carolina  Medical  Society,  Char- 
lotte, May  3,  1898. 


BLOUNT-THE  CHEMISTKY  OF  THE  STOMACH.  -g 

we  are  daily  called  upon  to  treat  a  class  of  patients  that  are  day 
by  day  becooiing  the  more  numerous.  From  bad  to  worse,  from 
worse  to  utter  despondency  many  of  these  patients  go  quietly 
on  their  way  because  m  many  instances  from  errors  of  omission 
and  commission  as  well  they  are  treated  in  a  routine  way,  be- 
cause of  that  lack  of  scientific  exactness  that  marks  the  profes- 
sion in  many  of  its  other  branches,  reminding  us  of  the  Epitaph 
"I  was  sick  and  desired  to  be  better  I  sent  for  the  doctor  and 
here  I  am."  The  pharmacists  having  seen  our  dilemma  have 
alas!  fallen  too  easy  a  prey  and  today  we  are  sold  by  the  gallon 
essence  of  pepsin.  Pan  Peptic  Elixir,  Pancreopepsin  and  innum- 
erable other  preparations.  Such  great  blindness  do  these  same 
pharmacists  attribute  to  us  that  they  advertise  and  expect  us  to 
make  use  of  all  the  ferments  in  one  combination  and  yet  does 
not  our  physiology  go  contrary  to  all  such  preparations  and 
prove  their  incompatability?  The  stomach  with  its  normal  ca- 
pacity of  five  pints  and  its  secretions  is  co  me  of  all  the  members 
the  most  remarkable.  Tho'  later  day  scientists  of  tiie  Schlatter 
type  may  prove  that  without  our  stomach  we  may  live  and  move 
and  have  our  being,  its  importance  was  immortalized  by  ^sop 
in  the  fable  of  Menenius  Agrippa,  a  former  Roman  consul  and 
general,  wherein  the  members  entered  into  a  league  and  cove- 
nant against  the  belly  and  held  firmly  to  their  position  until  the 
belly  starved  the  rebel  members  into  subjection.  What  was  true 
in  Menenius  Agrippa's  day  is  today  the  same,  and  daily  do  we 
bear  witness  to  some  poor  despised  dyspeptic  who  once  made 
the  proud  boast  that  his  belly  was  of  all  his  frame  the  strongest. 
Like  the  camel  that  bore  his  load  uncomplainingly,  in  true  camel 
fashion  until  the  last  straw  was  added,  so  the  belly,  if  continually 
overtaxed  will  in  time  give  way.  Of  no  ocher  member  Ccin  it  be 
more  truly  said  "that  he  who  transgresses  nature's  laws  must  pay 
the  penalty."  In  health  the  foods,  as  divided  by  Oilman  Thomp  - 
son  into  six  groups — water, — salts,  proteids,  starches,  sugar, 
fats  and  oils  enter  that  delicately  arranged  and  devised  labora- 
tory of  the  stomach  whereby  that  most  complex  of  chemical 
processes,  metabolism,  they  are  made  to  s^rve  their  intended 
purpose  as  (i)  nutrient,  (2)  heat  producing,  (3)  force  producing. 
In  the  lower  animals  that  God  given  instinct  prompts  them  to 
the  proper  selection  of  their  foods  both  quantatively  and  qualita- 


-gQ  BLOUNT-THE  CHEMISTRY  OF  THE  STOMACH. 

tivelv,  and  rarel}^  do  we  see  them,  when  left  entirely  to  their 
own  silecti')n,  transgress  those  laws  as  dictated  by  that  native 
instinct.  But  nran,  poor  nnan  !  civilization  has  done  too  nnich^ 
it  ha:,  made  him  depart  from  that  native  instinct,  and  from  his 
repeated  gross  insults  to  his  gastric  physiology  do  we  find  one 
or  another  train  of  symptoms  developing.  The  first  departure 
fron7  the  normal  condition  to  which  I  will  call  attention  is 
hyperacidity.  Hydrochloric  acid  is  one  of  the  normal  constitu- 
ents of  the  gastric  jaice  and  we  had  better  consider  its  impor- 
tance from  a  physiological  stand  point  before  we  enter  upon  a 
consideration  of  it  pathologically.  Hydrochloric  acid  acts: 
First:  as  an  antizymotic  or  antiseptic.  Second;  it  has  the  power 
to  covert  proenzymes  of  pepsin  and  zymogen  into  active  fv,rments 
in  a  short  time.  Third:  it  aids  in  the  regulation  of  peristalsis. 
Fourth:  hydrochloric  acid  with  the  aid  of  pepsin  transforms 
albuminous  bodies  into  peptones.  Fifth:  by  hydrochloric  acid 
cane  sugar  is  converted  into  invert  sugar  (dextrose  and  levulose). 
Sixth:  it  aids  in  bringing  into  solution  the  soluble  calcium  and 
magnesium  salts  introduced  intothe  blood. 

We  see,  therefore,  by  the  above  how  essential  it  is  that  we  should 
have  thorough  knowledge  of  its  detection  and  to  understand  the 
end  we  have  in  view  in  its  administration.  Bunge  sums  up  the 
entire  usage  of  hydrochloric  acid  and  cites  as  its  principle  object 
that  of  sterilization.  In  order  to  be  able  to  test  for  hydrochloric 
acid  we  must  first  procure  a  specimen.  The  method  of  procur- 
ing the  hydrochloric  acid  is  after  a  test  meal  and  the  one  most 
frequently  employed  is  that  of  Ewald  and  Boas.  This  test 
meal  includes  one  roll  or  a  piece  of  wheat  bread  and  eight 
ounces  of  water  or  tea  without  milk  or  sugar.  The  time  for 
securing  the  specimen  of  gastric  juice  is  one  hour  after  this 
meal.  Another  very  good  method  that  is  sometimes  employed 
is  at  8  a.  m.  tO  administer  a  small  piece  of  meat  scraped  and 
broiled,  a  soft  boiled  ego;^  boiled  rice,  one  glass  of  milk  and  a 
piece  of  bread,  then  at  12  m.  the  Ewald-Boas  test  meal.  Now 
one  hour  after  the  administration  of  the  last  meal  and  five  hours 
after  the  administr:jtion  of  the  first  meal  draw  ofT  by  means,  of 
the  lavage  tube,  the  stomach  contents.  The  advantage  to  be 
gained  from  this  double  test  meal  are  that  after  withdrawing 
the  stomach  contents  we  are  enabled  often   to   recogjiize  condi- 


BLOTNT— THE  CHKMISTKY  OF  THE  STOMACH.  ^qj 

tions  of  gastric  motility  and  secretion  before  we  analyze  the 
contents  thus  giving  us  an  insight  into  the  condition  in  question, 
and  confirmatory  of  what  we  will  find  subsequently  by  chemical 
analysis.  For  instance,  should  the  entire  bre.ikfast  meal  have 
disappeared  it  would  point  to  a  normal  digestion.  If  on  the 
contrary  we  find  an  absence  of  all  proteid  beef  and  egg  and 
presence  of  considerable  carbohydrate  rice  and  bread,  we  would 
in  all  probability  have  a  condition  of  hyperacidity  to  deal  with, 
while  an  absence  of  all  the  carbohydrates  and  presence  of  some 
of  the  beef  and  egg  would  point  to  hypochloridia  or  subacidity. 
The  presence  of  the  entire  meal  with  milk  uncurdled  would 
mean  impaired  motility  with  absence  of  acids  and  gastric  fer- 
ments. The  best  method  of  securing  a  specimen  of  gastric  juice 
is  after  the  introduction  of  the  stomach  tube  to  direct  the  patient 
to  bear  down  as  in  an  effort  at  defecation,  tho'  sometimes  the 
accompanying  nausea  involuntarily  accomplishes  this.  If  a 
failure  is  still  imminent  push  the  tube  further  in  or  partially  re- 
move and  if  the  abdominal  walls  are  flabby  external  abdominal 
p'-essure  will  sometimes  bring  about  the  desired  result.  Some- 
times a  small  particle  of  food  obstructs  the  eye  of  the  instrument, 
and  if  so,  a  little  water  poured  in  washes  away  the  offending  par- 
ticle and  again  resorting  to  the  above  methods  will  be  crowned  by 
success.  At  times  however,  a  little  suction  is  required  and  this 
is  most  easily  accomplished  by  means  of  Vanburen's  bladder 
syringe.  The  bulb  is  compressed  and  all  air  removed  and  the 
end  inserted  into  the  savage  tube.  Nature  abhorring  a  vacuum, 
the  bulb  refills  and  gastric  juice  is  thus  extracted.  Having  se- 
cured the  gastric  juice  we  will  proceed  to  its  analysis.  "Gunz- 
berg's  reagent,  as  modified  by  Boas,  is  a  very  delicate  test  and 
one  easily  applied.  The  solution  has  to  be  kept  in  a  dark  well 
stoppered,  bottle  and  even  then  should  be  frequently  renewed. 
I  always  buy  the  solution  ready  prepared  from  Eimer&  Amend, 
New  York.  It  consists  of  two  grammes  of  phloroglucin  and 
one  gramme  vanillin  dissolved  in  loo  grammes  of  80  per 
cent  alcohol.  A  few  drops  of  this  solution  is  added  to  the  same 
amount  of  filtered  gastric  contents.  This  is  placed  over  a  water 
bath  and  kept  just  below  the  boiling  point  until  slowly  evapo- 
rated. When  the  mixture  is  dried  a  fine  rose  tint  will  develop 
around  the  edges  if  hydrochloric  acid  is  present  in   the  propor- 


^02  BLOCNT-THE  CHEMISTRY  OF  THE   STOMACH. 

tion  of  0.5  per  thousand  ;  excessive  heat  however  is  utterly  de- 
structive to  the  test,  for  heat  in  excess  will  cause  an  appearance 
of  a  brown  or  brownish  red  color  which  resembles  the  color  pro- 
duced when  free  hydrochloric  acid  is  absent. 

Another  test  and  one  almost  as  delicate  and  always  to  be 
found  in  every  physician's  armamenta-ium  is  that  of  resorcin. 
This  solution  consists  of  five  (5)  grammes  of  lesublimed  resorcin, 
three  (3)  grammes  of  common  sugar  dissolved  in  100  C.  C.  of 
94  per  cent  alcohol.  Eight  or  ten  drops  of  the  filtered  gastric 
juice  and  half  the  number  of  drops  of  the  solution  are  carefully 
evaporated  on  a  porcelaine  plate  over  a  water  bath,  avoiding 
excessive  heat  as  formerly.  Free  hydrochloric  acid  in  excess 
will  be  indicated  by  "a  fine  vermillion  red  line  forming  down 
the  edge  of  the  solution  as  evaporation  proceeds,  while  the  color 
at  the  periphery  gradually  fades,  disappearing  entirely  after  a 
short  time,  leaving  a  redish  brown  stain."  Another  confirmatory 
test  for  hydrochloric  acid  is  found  in  testing  for  tree  acids.  The 
presence  of  free  acids  is  detected  by  Congo  red.  Congo  red  is 
made  into  an  aqueous  solution  and  into  this  solution  bibulous 
paper  is  dipped  and  allowed  to  dry.  This  paper  is  then  used  as 
an  indicator.  Dip  this  paper  into  the  filtrate  of  the  stomach 
contents  and  in  the  presence  of  free  hydrochloric  acid  or  organic 
acids  the  paper  turns  a  bright  blue.  Warm  gently  over  an 
alcoholic  flame  and  if  the  blue  color  is  produced  by  organic 
acids  the  gentle  heat  will  cause  the  blue  color  to  disappear, 
while  the  blue  color  if  produced  by  the  hydrochloric  acid  will 
upon  gentle  heat  turn  a  lighter  blue  ai;d  does  not  disappear 
unless  strongl}'  heated.  In  contradistinction  to  hyperacidity 
we  have  hypochloridia  or  subacidity.  In  subacidity  at  the  height 
of  digestion  hydrochloric  acid  and  with  it  pepsin  may  be  secreted 
but  in  smaller  amounts  than  normal.  Here  however,  it  is  en- 
tirely combined  with  the  food  as  combined  hydrochloric  acid 
and  not  to  be  detected  by  any  of  the  tests  as  given  above. 
With  unimpaired  gastric  motility,  subacidity  may  be  accompa- 
nied by  few  or  no  symptoms,  but,  permit  motility  to  become 
bad  or  slightly  insufficient  and  rapid  decomposition  of  the 
stomach  contents  takes  place  because  the  amount  of  hydrochlo- 
ric acid  is  not  sufficient  to  inhibit  or  prevent  the  action  of  micro 
organisms.  As  a  result  of  this  decomposition  gastiic  discomfort 
and  sometimes  intestinal    distention    supervene.      There   are   no 


BX,OUNT-THE  CHEMISTRY  OF  THE  STOMACH.  ^g^ 

pathognomonic  signs  of  subaciciity,  but  given  by  examination  an 
absence  of  hydrochloric  acid,  presence  of  organic  acids  and  upon 
removal  of  test  meal  we  find  that  amalosis  has  proceeded  more 
rapidly  since  the  hydrochloric  acid  was  not  there  to  interrupt 
the  continued  action  of  the  ptyalin,  and  on  the  other  hand  the 
digestion  of  meats,  eggs,  etc.,  unsatisfactory,  then  we  would 
conclude  we  had  a  case  of  subacidity  to  deal  with,  provided 
carcinoma  and  chronic  gastritis  were  excluded. 

Pepsin,  the  proteolytic  ferment  of  the  gastric  juice  is  active 
only  in  an  acid  medium  and  the  ideal  acid  for  this  acidity  is 
hydrochloric  acid,  though  any  of  the  other  acids  v^ill  suffice.  Hy- 
drochloric acid  acts  on  the  pepsinogen  or  propepsin,  converting 
it  into  pepsin.  We  possess  no  chemical  test  for  pepsin,  it  being 
of  a  qualitative  nature,  viz;  its  effect  in  acid  solution  upon  proteid 
substances.  These  test  tubes  number,  one,  two  and  three,  re 
spectively,  into  each  of  which  a  thin  slice  of  egg  albumen  has 
been  previously  added.  Into  No.  i,  is  put  3  C.  C.  of  gastric 
juice.  Into  No.  2,  is  put  3  C.  C.  of  gastric  juice  to  which  hydro- 
chloric acid  has  been  added,  while  in  No.  3,  acidulated  as  in 
No.  2,  a  few  grains  of  pepsin  is  added.  The  tubes  are  now 
placed  in  a  temperature  of  104°  F.  for  three  hours.  In  the  absence 
of  a  proper  apparatus  for  the  maintenance  of  the  temperature 
at  this  point  I  wrap  the  tubes  up  in  cotton  and  place  them  under 
the  stove,  taking  care  to  avoid  excessive  heat.  If  at  the  end  of 
thiee  hours  all  three  tubes  show  digestion  by  the  rounding  off  and 
solution  of  the  egg  albumen,  the  specimen  contained  pepsin,  if 
Nos.  2  and  3  only  show  digestion,  the  contents  show  pepsinogen 
but  no  pepsin;  while  if  No.  3  only  shows  traces  of  digestion, 
the  specimen  contained  neither  pepsin  or  pepsinogen.  Lactic 
acid  when  found  in  the  stomach  contents  has  either  been  intro- 
duced in  the  food,  as  such,  or  is  the  product  of  abnormal  fer- 
mentation. After  the  injection  of  food  in'carcinoma,  lactic  acid 
may  be  formed  and  to  a  slight  extent  also  in  subacidity.  •  The 
presence  of  lactic  acid  in  large  amounts  points  strongly  to 
carcinoma.  In  an  examination  for  the  presence  of  lactic  acid 
we  must  be  sure  none  has  been  introduced  in  the  food.  To 
overcome  this  difficulty  Boas  has  devised  a  meal  consisting  of 
oatmeal,  to  which  only  a  little  salt  has  been  added.  The  even- 
ing prior  to  the  administration  of  the  above  meal   wash  out  the 


^g,  BLOUNT-THE  CHEMISTRY  OF  THE  STOMACH. 

Stomach  until  no  food  particles  can  be  found,  and  on  the  morn- 
ing following  administer  Boas  meal  as  directed  above.  Lactic 
acid  found  in  the  gastric  ffltrate  one  hour  after  the  above  meal 
would  point  strongly  to  carcinoma.  Uffelman  has  devised  the 
best  chemical  test  for  lactic  acid.  Ten  (lo)  C.  C.  of  a  4  per  cent 
solution  of  carbolic  acid  are  mixed  with  twenty  (20)  C.  C.  of 
water  and  a  drop  of  strong  solution  of  ferric  chloride  added.  A 
beautiful  amethyst  blue  color  is  produced  which  turns  a  canary 
yellow  when  treated  with  with  gastric  juice  containing  lactic 
acid. 

For  all  practical  purposes  the  sense  of  smell  will  suffice  for  the 
detection  of  butyric  acid,  being  that  of  rancid  bucter.  Acetic 
acid  can  likewise  be  detected  by  the  nasal  sense. 

While  the  importance  of  being  able  to  make  the  above  analysis 
cannot  be  over-estimated,  it  is  of  equal  importance  to  be  able  to 
examine  the  motor  or  peristaltic  function.  Schlatter  has 
proven  that  a  man  may  live  without  his  stomach,  and  daily  ob- 
servation teaches  us  that  the  secretory  and  absorptive  functiuns 
of  the  stomach  are  not  essential,  for  internal  digestion  would 
suffice.  Hydrochloric  acid,  pepsin  and  gastric  absorption  may 
all  be  wanting,  and  yet  life  be  maintained,  and  even  a  fair  degree 
of  health.  Let  the  motor  function  be  impaired,  however,  and 
the  food  will  remain  in  the  stomach  and  accumulate.  Even  if  a 
normal  gastric  juice  were  possible  when  the  peristalsis  is  para- 
lized,  the  food  could  be  only  partly  digested,  for  pepsin  like 
the  other  ferments,  has  the  property  of  changing  an  almost  un- 
limited amount  of  proteids,  providing  the  products  of  the  action 
SiVQ  refnoved  vihtn  formed,  and  the  temperature  at  a  favorable 
point,  as  it  appears  to  act  by  its  presence  not  being  itself  de- 
stroyed or  changed  by  the  reaction.  For  the  general  practi- 
tioner Senbe's  method  affords  an  insight  into  the  condition  of 
gastric  peristalsis,  i.  e.  "'to  determine  after  a  definite  average  of 
time  of  six  to  seven  hours  after  a  meal  of  50  grammes  bread, 
200  grammes  beef  steak,  and  a  glass  of  water,  or  two  hours 
after  a  Ewald  test  breaksast,  whether  solid  contents  are  still  to 
be  found  in  the  stomach." 

Another  test  for  gastric  motility  and  peristalsis  is  dependent 
upon  the  fact  that  salol  is  not  altered  in  the  stomach,  but  it  is 
changed  by  the  intestinal  juices  into  salicylic  acid   and  phenol. 


BLOUNT-THE  CHEMISTRY  OF  THE  STOMACH. 

In  normal  digestion  salicylic  acid  will  be  found  in  the  urine  in 
from  40  to  75  minutes  after  the  ingestion,  and  a  failure  in  its 
apJDearance  within  these  limits  would  indicate  an  impaired  gastric 
motility.  Huber  has  improved  this  method  by  ascertaining  that 
in  health  salicyluric  acid  should  disappear  from  the  urine  in  24 
hours,  whereas,  when  gastric  peristalsis  is  retarded  the  reaction 
continues  distinct  even  as  long  as  48  hours.  Salicyluric  acid  is 
recognized  in  the  urine  by  the  violet  color  produced  on  the 
addition  of  neutral  ferric  chloride  solution.  The  value  of  the 
function  of  gastric  absorption  cannot  be  overestimated.  It  is 
best  detected  by  the  ingestion  of  potassium  iodide.  This  sub- 
stance when  taken  in  solution  into  the  stomach  should  appear  in 
the  urine  and  saliva  in  6}4  to  15  minutes.  Wet  apiece  of  starch 
paper  with  the  saliva  ot  the  patient  every  two  minutes  after  the 
potassium  iodide  is  taken,  touching  the  spot  with  fuming  nitric 
acid.  Immediately  upon  the  excretion  of  the  iodide  a  blue  color 
is  apparent  on  the  starch  paper  and  should  this  color  appear 
later  than  fifteen  minutes,  then  the  rate  of  absorption  is  reduced 
proportionately  to  the  length  of  time  of  its  appearance  after  the 
expiration  of  the  fifteen  minutes.  Another  method  of  testing 
power  ot  absorption  is  by  giving  two  decigrammes  of  powdered 
rhubarb  which  gives  a  red  color  in  the  urine  with  liquor  potass^ 
in  fifteen  minutes.  Whenever  gastric  motility  is  impaired,  ab- 
sorption lessened,  and  the  secretions  disturbed,  fi'om  accumula- 
tion and  distention  we  will  in  time  have  a  condition  known  as  a 
gastric  dilatation.  This  is  best  detected  by  filling  the  stomach 
with  carbon  dioxide,  and  by  palpitation  and  percussion  map  out 
the  distended  organ.  This  is  best  accomplished  by  dissolving 
one  teaspoonful  of  bicarbonate  of  soda,  and  one  of  tartaric  acid 
in  separate  glasses,  containing  four  ounces  of  water  each.  Direct 
patient  to  first  drink  solution  of  tartaric  acid  and  then  that  of 
bicarbonate  of  soda.  Quickly  an  evolution  of  carbon  dioxide 
takes  place  and  the  outline  of  the  stomach  can  be  easily  made 
out.  The  tests  given  above  are  sufficiently  elaborate  to  enable 
a  careful  practitioner  to  analyze  and  diagnose  his  cases  and  the 
diagnosis  once  correctly  made,  the  doctor  is  already  half  way 
on  the  road  to  successful  treatment.  In  the  treatment,  however, 
it  is  to  be  borne  in  mind  that  "a  logical  and  individualizing  diet 
is  a  more  potent  factor  than  medicine." 


^g6     HILL,-VERATRtrM  VIRID3  IN  PARaN-CHYMATOUS  INFLAMMATION. 

A  careful  adherence  to  the  principles  herein  laid  down  will 
change  our  practice  trom  that  of  empiricism  to  almost  scientific 
exactness^  and  our  labors  will  reach  a  rich  harvest,  ftrst  of  all  in 
personal  satisfaction,  and  second  in  a  daily  increasing  cP.entele 
that  not  every  one  of  our  cosfrers  will  be  able  to  take  away. 
There  is  no  field  more  fertile  in  clinical  material,  no  field  more 
generally  neglected  by  the  profession  at  large,  and  no  field  that 
if  properly  cared  for  will  yield  a  richer  harvest. 

I  am  fully  aware  that  I  have  advanced  nothing  new  but  if,  in 
passing  in  review  the  method  and  chemical  tests  as  devised  and 
adopted  by  the  profession,  I  shall  arouse  a  full  and  lengthy  dis- 
cussion, from  which  I  liope  to  profit,  I  shall  feel  more  than  amply 
repaid. 


VERATRUM    VIRIDE:    WITH    ESPECIAL  REFERENCE 

TO   ITS  THERAPEUTIC  USES  IN    SEROUS  AND 

PARENCHYMATOUS  INFLAMjMATIONS.* 

By  D.  J.  Hill,  M.D.,  Lexington,  N.  C. 

VERATRUM  vinde,  or  swamp  hellebore,  is  a  perennial  her- 
bal plant  formerly  thought  to  exist  only  in  this  country, 
being  found  in  certain  marshy  sections  of  the  Northern 
Atlantic  States,  and  as  far  south  as  the  Caroiinas.  But  it  is 
now  known  that  veratrum  album,  which  is  practically  identical 
with  this  plant,  grows  in  abundance  in  certain  European  States. 
The  several  forms  of  the  drug  as  accepted  by  the  United  States 
Pharmacopoeia  are  made  from  the  fresh  rhizome  and  roots  of  the 
plant,  which  should  be  gathered  in  the  winter.  Historically 
there  is  but  little  to  be  said  of  this  drug.  It  is  known  that  some 
of  the  Medicine  Men  of  the  native  Indian  tribes  were  acquainted 
with  its  peculiar  intoxicating  qualities,  and  it  is  alleged  that 
some  tribes  used  it  as  an  ordeal  or  test  of  strength  and  vigor. 
The  attention  of  the  medical  profession  was  first  called  to  its 
use  as  a  cardiac  depressant  by  the  publication  of  a  paper  by  Dr. 

*Read  at  45th  Annual  Meeting  of  the  North  Carolina  Medical  Society,  Char- 
lotte, May  3,  1898. 


HILL— VERATRUM  VIRIDE  IN  PARENCHYMATOUS  INFLAMMATION. 

Osgood  in  1S35,  which  was  followed  by  the  investigation  of  Dr. 
Norwood.  It  is  not  the  purpose  of  this  paper  to  enter  into  a 
detailed  treatise  on  its  two  principal  alkaloids,  jervine  and  vera- 
troidine,  but  rather  to  deal  with  the  drug  as  a  whole.  Veratrum 
viride  not  only  lessens  the  force  and  slows  the  time  of  theheiirt 
beat,  but  it  also  acts  as  a  spinal  depressant,  and  in  this  way 
differs  from  the  other  drugs  belonging  to  this  class.  Its  de- 
pressing effect  upon  the  cord  is  probably  due  to  the  veratroidine. 
Professor  Wood  in  summing  up  the  physiological  action  of  vera- 
trum  viride  says:  "It  is  a  powerful  spinal  and  arterial  depres- 
sant, exerting  little  or  no  direct  influence  upon  the  cerebral 
centers.  In  full  therapeutic  doses  it  lov/ers  the  pulse-rate  both 
by  a  direct  action  on  the  muscle  (jervine)  and  by  stimulating  the 
inhibitory  nerves  (veratroidine);  it  diminishes  the  force  of  the 
hea.t  beat  by  a  direct  influence  on  the  cardiac  muscle  (jervine), 
and  produces  a  general  vasomotor  paralysis  (jervine)  more  or 
less  complete  according  to  the  size  of  the  dose." 

As  to  the  positive  action  of  veratrum  viride;  the  frequency 
and  force  of  the  pulse  of  inflammation  and  irritation  can  abso- 
lutely and  certainly  be  controlled  by  its  timely  and  judicious 
administration.  And  of  all  the  positive  heart  sedatives  it  is  un- 
questionably the  safest.  It  is  not  probable  that  a  single  dose 
even  of  enormous  size,  administered  by  the  mouth,  would  kill, 
from  the  fact  that  an  over  dose  will  usually  produce  prompt 
emesis.  Recovery  after  the  injestion  of  an  ounce  of  the  tincture 
has  been  reported,  and  recently  Dr.  Tuttle  records  a  case  in 
which  four  teaspoonfuls  were  taken  instead  of  four  drops  in  an 
hour  with  no  worse  results  ihar  severe  vomiting,  palor  and  pros- 
tration. It  is  true  that  the  heroic  administration  of  the  drug 
may  sometimes  produce  the  appearance  of  dangerous  collapse 
but  if  it  does,  this  condition  should  occasion  no  alarm,  as  it  is 
only  transient — the  patient  promptly  rallying  even  unaided. 
However,  there  is  no  objection  to  giving  a  small  amount  of  al- 
coholic stimulant  to  assist  reaction. 

Professor  Wood,  summarizing  again  in  a  general  way,  says 
there  are  only  two  rational  indications  for  the  use  of  veratrum 
viride — namely,  \.o  reduce  spinal  action  and  to  reduce  arterial  ac- 
tion. But  if  we  employ  the  drug  to  reduce  excessive  heart-ac- 
tion in  hypertrophy  and  in   sthenic   fever  etc.,  we  surely  would 


^q3     HIT,L,-\"EHATRUM  VIRIDE  in  parenchymatous  INFLAiMMATION". 

not  expect  it  to  reduce  the  rapid  pulse  of    exhaustion    as    found 
in  tlie  last  stages  of  phthisis  and  other  wasting  diseases. 

Tlie  late  Professor  Lynch,  of  Baltimore,  considered  veratrum 
viride  almost  a  specific  in  sthenic  craupous  pneumonia;  and  I 
am  sure  we  may  at  least  modify  the  course  of  the  most  violent 
cases  of  this  trouble  by  its  timely  and  judicious  employment. 
At  the  outset  of  this  much  dreaded  disease  it  is  of  paramount 
importance  to  allay  vascular  excitement,  as  this  necessarilly 
leads  to  a  rapid  depression  of  the  vital  forces.  One  predeces- 
sor resorted  to  venesection  to  accomplish  this  end,  but  the  gen- 
eral experience  of  the  profession  led  to  the  almost  universal 
abandonment  of  this  practice,  as  it  was  found  th  .t  in  this  dis- 
ease it  involved  absolute  loss  of  vital  po'ver,  and  there  is  a  posi- 
tive distinction  between  deprsssion  of  the  vital  forces,  and  abso- 
lute loss  of  power.  I  beg  to  insist  that  it  should  be  employed  in 
the  early  stages  only — during  the  period  of  congestion,  or  hy- 
persemia.  Giving  it  after  hepatization  comes  on  is  contra-indi- 
cated, and  worse  than  useless.  In  the  stage  of  congestion,  the 
patient  should  be  brought  fully  under  its  influence  as  quickly  as 
possible — for  instance,  giving  from  four  to  six  drops  of  the 
tincture,  waiting  one  hour,  and  giving  in  one  drop  doses  every 
fifteen  minutes — closely  watching  the  effect  until  the  pulse  is 
reduced  to  70  or  60  per  minute,  and  then  graduating  the  dose 
so  as  to  keep  up  effect  till  hepatization  sets  in.  Always  carefully 
enjoining  the  recumbent  posture.  This  plan  faithfully  prosecuted 
is  far  from  chance  of  accident  of  over  dose  or  accumulative 
effect  and  can  give  only  the  best  results.  You  have  thus  attained 
all  the  good  that  could  possibly  result  from  the  use  of  the  lancet 
and  still  have  a  resivoir  of  much  needed  blood  safely  stowed 
away  in  the  large  venous  trunks  of  the  body  to  draw  upon  later 
on  in  the  progress  of  the  disease.  In  other  words,  you  have 
temporarily  lowered  the  vitality  without  in  anywise  destroying 
the  vital  forces.  While  not  claiming  for  veratrum  viride  a  pos- 
itively specific  action  in  pneumonitis;  still,  if  the  above  plan  of 
administration  is  carefully  prosecuted,  we  will  find  the  progress 
of  the  disease  favorably  modified,  and  resolution  coming  on 
more  promptly.  It  is  equally  efficacious  in  pleuritis.  Giving  it 
so  as  to  diminish  the  force  and  rate  of  the  heart  beat  as  above, 
with  an  opiate  to  relieve  pain,  and   proper   counter  irritation,  if 


PARROTT-THE  COUNTRY  SURGEON  AND  HIS  WORK.  -.„„ 

deemed  advisable,  we  will  rarely  if  ever  have  an  effusion.  In  the 
early  stages  of  acute  amygdalitis  its  prompt  administration  with 
morphine  if  there  be  much  pain  will  often  determine  and  hasten 
resolution.  It  may  be  given  with  good  effect  in  hepatitis  and  in 
acute  inflammation  of  the  other  viscera.  In  the  hands  of  many 
practitioners,  one  bar  to  the  employment  of  veratrum  viride  in 
certain  other  troubles  where  such  a  heart  sedative  is  indicated 
has  been  its  tendency  sometimes  to  cause  vomiting.  This  how- 
ever may  usually  be  successfully  overcome  by  carefully  regulat- 
ing the  dose  and  giving  with  tincture  of  ginger.  Dr.  Barker 
relied  on  veratrum  viride  to  reduce  vascular  excitement  in  puer- 
peral phlebitis  and  puerperal  peritonitis,  given  with  tr.  ginger 
as  stated  above.  The  pulse  of  puerperal  peritonitis  may  readily 
and  easily  be  controlled  without  producing  vomiting.  Dr. 
Walker  reports  a  case  of  persistent  priapism  finally  relieved  by 
veratrum  viride  after  having  resisted  a  large  number  of  other 
drugs;  and  I  have  obtained  excellent  results  by  giving  large 
doses  in  acute  mania.  But  of  all  the  good  things  to  be  said  of 
this  drug,  its  greatest  field  of  usefulness  is  undoubtedly  in  acute 
serous  and  parenchymatous  inflammations,  and  we  obtain  the 
most  marked  and  favorable  results  under  this  head  from  its  ad- 
ministration in  pneumonia  and  pleurisy. 

It  has  long  been  a  custom  with  many  obstetricians  to  give 
veratrum  viride,  and  often  in  large  doses,  to  control  puerperal 
eclampsia.  I  simply  mention  this  fact  in  closing  to  condemn 
the  practice.  It  is  unscientific  and  should  never  be  given  in 
such  cases. 


THE  COUNTRY  SURGEON  AND  HIS  WORK.* 
By  James  M.  Parrott,  M.D.,  Kinston,  N.  C. 


THERE  is  certainly   no  branch  of  our  noble  profession  more 
worthy  of  the  careful  study  which  has  been  given  it  than 
surgery.      Like  every  distinctive   subject  it   has  its  own 
special  and  peculiar  field  of  work,   and    the  surgeon,  character- 

*Read  at  45th  Annual  Meeting  of  the  North  Carolina  Medical  Society,  Char- 
lotte, May  3,  1898. 


400 


PARROTT-THE  COUNTRY  SURGEON  AND  HIS  WORK. 


istics  of  his  own.  Hence  in  order  that  one  may  approach  even 
closely  to  perfection  in  surgery  one  must,  of  necessity,  be  pe- 
culiarly adapted  to,  and  especially  trained  for,  his  work.  Like 
the  poet  the  surgeon  is  born,  but  unlike  the  farmer  he  must  also 
be  made.  One  may  possess  the  natural  endowments  requisite 
for  success  in  this  particular  line  of  our  work,  yet  one  would  of 
necessity  fail  without  the  required  training.  Special  prepara- 
tion is  as  essential  to  success  in  this  branch  of  our  noble  profes- 
sion as  it  is  in  the  disease  peculiar  to  the  eye,  the  ear  or  any 
other  organ.  While  all  of  us  cannot  be  experts  in  surgery,  be- 
cause of  the  lack  of  skill  or  the  proper  training,  yet  I  do  be- 
lieve that  the  general  practitioner  can  and  should  be  more  of  a 
surgeon  than  the  average  one  is.  No  man  can  be  perfect  in  any 
one  medical  subject,  and  hence  we  should  not  expect  to  be  per- 
fect in  all;  why  then  should  we  make  ourselves  believe  that  we 
are  not  competent  to  do  surgical  work  because  of  our  short-com- 
ings and  refer  our  patients  to  our  city  friends  when  they  them- 
selves are  imperfect?  Let  us  then  study  the  subject  closely, 
equip  our  offices  with  the  instruments  usually  required  in  ordin- 
ary surgical  work,  and  then  do  the  work,  thus  saving  our  patients 
the  annoyance  and  expense  of  travelling  to,  and  remauiing  in  a 
distant  hospital,  and  at  the  same  tiriie  save  to  ourselves  the  re- 
muneration and  reputation  which  our  city  brother  would  thus 
derive. 

I  would  not  for  one  moment  advise  a  tyro  to  endanger  the 
life  of  a  patient  by  performing  unassisted  a  most  difficult  opera- 
tion, but  I  do  advise  him  to  properly  equip  himself  so  that  he 
can  do  the  common  surgery  which  he  as  a  general  practictioner 
may  be  called  upon  to  do.  But  says  one,  "how  can  I,  with  limited 
means,  equip  myself  with  instruments  and  acquire  the  skill 
necessary  to  the  successful  prosecution  of  surgical  work,  and 
after  I  am  prepared  what  results  can  I  expect  to  obtain?"  The 
answer  to  this  question  which  has  often  been  propounded  to  me 
embodies  the  essential  features  of  this  paper,  presented  as  it  is 
in  my  own  feeble  manner  with  the  hope  that  it  prove  of  value  to 
some  one  attempting  or  just  beginning  to  walk  in  surgical  ways. 

It  is  needless  to  speak  of  the  advantage  of  hospital  experience 
to  one  intending  to  be  a  surgeon.  Its  value  connot  beoveresti- 
mated,  but  since  it  cannot  be  enjoyed  by  every  one  some  substi- 
tute must  be  offered.      To  one  without  such  opportunities  I  would 


PARllOTT-THE  COUNTRY  SURGEON  AND  HIS  WORK.  .q^ 

say  go  to  the  dead-house  and  there  learn  the  technique  of  every 
operation.  Such  instruction  can  be  now  easily  and  quickly  ob- 
tained in  any  of  our  large  cities.  After  thus  becoming  familiar 
with  the  instruments  and  operations  one  is  then  prepared  to  be- 
gin surgical  work.  At  first  one  should  only  undertake  the  most 
simple  operations  and  then  as  ones  experience  grows  the  treat- 
ment of  the  more  difficult  cases  may  be  undertaken,  thus  grad- 
ually reaching  the  goal  to  which  one  aspires  without  ever  being 
a  tyro  in  the  true  sense  of  the  v/ord.  The  time-honored  custom  of 
studying  with  an  old  doctor  as  a  preceptor  gave  valuable  assis- 
tance in  obtaining  experience  which  cannot  be  over-estimated. 
Just  here  let  me  say  that  I  regret  most  thoroughly  the  later-day 
tendency  to  depart  from  this  old  medical  usage,  and  I  hope 
to  see  the  day  dawn  very  early  when  medical  men  like  the  drug- 
gist will  be  required  to  have  some  practical  experience  before 
they  are  allowed  to  graduate  After  the  young  surgeon  has 
thus  been  gradually  educated,  and  has  by  these  means  gained 
confidence  in  himself,  and  has  learned  the  modus  operandi  of  his 
instruments,  he  is  prepared  to  branch  out  into  a  strictly  surgical 
field. 

To  the  surgeon  perhaps  even  more  than  to  the  physician  the 
question  of  nursing  is  most  important.  With  the  country  prac- 
titioner it  is  often  most  perplexing  and  exceedingly  annoying. 
In  almost  every  community  there  is  some  one  who  has  a  peculiar 
knack  along  this  line  and  after  careful  instruction  by  the  sur- 
geon concerning  the  particular  case  to  be  nursed,  he  can  by  the 
close  attention  of  the  operator  render  with  wonderful  skill  the 
necessary  assistance.  In  my  own  country  surgical  practice  I 
often  send  quite  a  distance  for  a  person  who  has  nursed  for  me 
several  cases  of  the  variety  of  disease  I  am  about  to  treat.  In 
this  way  I  find  my  work  about  as  effective  as  that  obtained  by 
the  assistance  of  the  trained  nurse.  However,  professional  nurses 
are  now  numerous,  they  can  be  easily  secured  and  should  be  for 
a  serious  case  when  practical. 

The  question  of  assistance  at  the  time  of  operation  is  im- 
portant. Of  course  in  the  country  this  is  necessarily  crude,  but 
after  a  short  experience  one  soon  learns  to  meet  single  handed 
almost  all  emergencies.  The  routine  work  of  the  assistant  can 
be  easily  done   by  a  colleague   or  by  some  one  accustomed   or 


.Q2       PARROTT— THE  COUNTRY  SURGEON  AND  HIS  WORK. 

adapted  to  such  work.  It  is  wonderful  how  nicely  a  non-med- 
ical man  can  assist  in  a  surgical  operation  if  he  be  cool-headed 
and  possesses  a  stout  heart.  I  have  for  a  long  time  and  in  many 
cases  depended  upon  them  almost,  and  frequently  entirely  for 
assistance,  and  in  no  case  have  I  ever  been  annoyed  by  their 
ignorance  or  hampered  by  their  lack  of  experience.  This  may 
be  due,  however,  partly  to  the  fact  that  I  have  arradually  grown 
accustomed  to  their  unskillfuUness.  The  inexperienced  assis- 
tantlike the  raw  soldier  does  not  know  and  consequently  cannot 
comprehend  the  dangers  of  certain  emergencies  which  may 
arise  and  so  is  not  as  easily  rattled  as  the  more  experienced. 

Every  operator  and  particularly  the  country  surgeon  should 
always  be  on  the  lookout  for  any  emergencies  which  may  arise. 
Tact,  skill  and  an  intimate  knowledge  of  the  physiology  and 
anotomy  of  man  and  the  therapeutic  use  of  drugs  are  of  course 
absolutely  essential  to  the  successful  avoidance  of  many  reverses 
while  a  thorough  acquaintance  with  the  various  uses  to  which 
the  different  instruments  may  be  put  will  supply  the  knowledge 
needed  in  meeting. the  remaining  emergencies.  We  should  be 
so  accustomed  to  our  instruments  that  one  may  be  very  readily 
used  if  necessary  for  half  a  dozen  purposes.  For  example  if  the 
needle  holder  be  absent  the  artery  forceps  can  be  used  in  its 
stead  and  when  the  dilator  is  not  at  hand  the  instrumental  hem- 
astatic  may  again  be  called  into  service.  The  grooved  director, 
the  chief  use  of  which  in  my  opinion  is  to  aid  the  ignorant  sur- 
geon, may  be  used  as  a  probe,  while  the  probe  can  be  used  as 
an  aneurism  needle  or  a  retractor.  This  diversified  use  of  in- 
struments not  only  obviates  the  necessity  for  so  much  apparatus 
but  also  aids  in  meeting  the  emeigency  of  a  broken  or  absent 
instrument. 

Just  before  each  operation  the  instruments  and  dressings 
should  be  carefully  sterilized.  My  own  preference  is  the  small 
Arnold's  sterilizer.  This  can  be  easily  heated  on  the  common 
coal  stove  and  may  be  convieniently  carried  in  the  buggy.  The 
instruments  should  be  carefully  cleansed  in  carbolized  water  after 
each  operation.  They  should  be  carefully  dried  before  being 
replaced  in  the  instrument  case.  When  an  operation  is  to  be 
performed  in  the  country  or  out  of  the  office  a  medium  size  grip 
or  brief-bag,  lined  each  time  with  a  freshly  sterilized  towel  is  a 


PARROTT-THE  COUNTRY  SURGEON  AND  HIS  WORK 

very  convenient  case  in  which  to  carry  the  dressings  and  instru- 
ments. 

The  question  of  asepsis  and  antisepsis  is  really  about  the 
most  important  one  likely  to  confront  a  country  surgeon.  Per- 
mit me  to  suggest  that  if  the  instruments  are  cleansed  and  kept 
clean  as  above  described  the  problem  of  preventing  sepsis  is 
much  simplified.  In  town  and  country  surgery  we  are  not  an- 
noyed by  an  impure  atmosphere.  This  is  most  fortunate.  At- 
mospheric impurities  such  as  are  found  in  our  cities  and  hos- 
pitals are  no  doubt  the  cause  of  infection  in  95  per  cent,  of  the 
cases  of  septic  surgery.  Recently  while^  in  London  I  exposed 
a  medium  for  7  seconds  in  a  ward  in  a  large  hospital  and  in  due 
time  saw  grow  several  very  large  colonies  of  infective  organisms, 
later  I  exposed  the  medium  in  my  office  30  minutes  and  failed 
after  culture  to  find  any  pus  cocci.  This  to  my  mind  explains 
the  cause  of  the  very  remarkably  low  mortality  in  country  sur- 
gery. 

x\s  to  antiseptics  I  consider  carbolic  acid  the  best  for  all- 
round  work,  though  for  certain  purposes,  especially  for  cleans- 
ing the  hands  of  the  surgeon  and  the  field  of  operation  the  bi- 
chloride of  mercury  is  perhaps  better.  The  hands  of  the  sur- 
geon should  be  thoroughly  scrubbed  with  green  soap  and  then 
carefully  and  slowly  bathed  in  a  i-iooo  solution  bichloride  of 
mercury,  this  being  preceeded  by  an  application  of  alcohol  or 
turpentine  and  followed  by  careful  rinsing  with  strongly  carbol- 
ised  water.  The  patient  is  treated  in  a  similar  manner,  the 
whole  process  being  gone  through  with  very  slowly  and  carefully. 
Because  of  the  absence  of  the  septic  germs  in  the  atmosphere 
and  on  the  instruments,  this  method  is  always  sufficient.  During 
the  operation  of  course  perfect  cleanliness  should  be  observed 
and  the  wound  carefully  protected.  Lacerating  and  picking  in 
pieces  a  wound  by  an  unskillful  or  ignorant  operator,  or  the  too 
free  use  of  over  strong  antiseptics  during  or  after  an  operation 
is  more  often  the  cause  of  the  commencement  of  suppuration 
than  direct  or  immediate  infection.  In  my  own  work  during 
the  past  three  years  I  have  not  had  a  single  case  of  pus  forma- 
tion following  an  operation  and  only  one  case  of  infection  in 
accidental  wounds.  The  value  of  the  free  use  of  boiled  or  steril- 
ized water  during   an    operation   cannot  be   over  estimated.     I 


^rsA  PARKOTT-THE  COUNTRY  SURGEON  AND  HIS  WORK. 

404 

prefer  tb.e  boiled  water  which  has  been  carefully  covered  and 
alio  yed  to  coed  to  water  which  has  been  sterilized.  The  pans 
or  boA'ls  fLirnished  by  the  farntly  should  be  carefully  washed 
with  oarboljzed  water 'before  being  used.  The  towels  supplied 
by  the  patient  should  be  boiled  or  if  this  is  not  convenient  washed 
in  a  carbolic  acid  solution.  In  laparotomies  Thiersch's  solution 
is  a  very  valuable  antiseptic  and  is  to  be  prefered   to  all' others. 

The  subject  of  dressi-ngs  is  very  important.  My  own  expe- 
rience teaches  me  to  rely  on  cheese  cloth  cut  into  the  proper 
size.  From  sterilized  cheese  cloth  we  can  easily  make  bichloride, 
iodoform  or  carbolic  acid  gauze  by  soaking  it  in  the  solution  of 
the  antiseptic  we  desire  to  use,  and  permiting  it  then  to  slowly 
dry.  All  our  dressings  should  be  carefully  kept  in  screw-top 
jars,  especially  the  medicated  gauzes.  Iodoform  gauze  can  be 
easily  made  from  iodoform  emulsion,  but  it  is  preferable  to  pur- 
chase this  from  some  reliable  manufacturer.  I  never  depend 
upon  or  use  previously  medicated  gauzS  except  in  emergency 
work.  Just  here  let  me  say  that  in  my  opinion  iodoform  is  not 
so  good  a  germicide  as  it  is  a  disinfectant,  even  boracic  acid  in 
many  instances  being  better  as  an  antiseptic.  Musquito  bar  cut 
and  rolled  in  the  proper  manner  forms  not  only  the  cheapest 
but  the  best  bandage  material.  If  it  is  dampened  before  being 
applied  its  efficacy  is  greatly  increased.  Bleached  domestic  is 
another  valuable  bandage  material  and  can  often  be  used  to  a 
great  advantage.  All  of  us  can  certainly  afford  a  home  rrade 
bandage  roller  and  armed  with  this  our  wives  and  sisters  in  a 
few  hours  can  make  enough  bandages  to  supply  our  wants  in  a 
great  many  cases.  By  them  our  cheese  cloth  dressings  can  also 
be  made. 

The  emergency  bag  deserves  our  most  careful  attention.  It 
is  second  to  the  instrument  case  the  valuable  aid  to  the  country 
surgeon.  The  most  convenient  case  of  this  character  is  a  16  inch 
obstetrical  bag  containing  the  following,  viz  :  Absorbent  cotton, 
bandages  and  gauze  (may  be  medicated),  a  bottle  of  carbolic 
acid,  4  ounces  of  chloroform,  2  ounces  of  alcohol,  hypodermic 
tablets  of  morphia  and  strychnia,  the  instruments  usually  found 
in  an  ordinary  pocket  case,  one  large  scalpel,  dressing  forceps, 
two  pair  Pean  artery  forceps,  half  dozen  spear  pointed  needles, 
one  skein  of  medium  size  braided  silk,  one  tank  of  cat  gut,  one 


PAKTOTT-  THE  COUNTRY  SURGEON  AND  HIS  WORK.  ^^^ 

Esmarch's  constrictor,  one  Esmarch's  inhaler,  one  small  saw, 
adhesive  plaster,  collodion  and  cocaine.  With  this  outfit  always 
ready  one  is  constantly  prepared  to  meet  promptly  almost  any 
emergency  which  may  arise.  I  was  once  enabled  to  go  to  a  dis- 
tance from, my  office,  and  with  the  assistance  of  Dr.  John  A. 
Pollock,  to  perform  a  double  leg  amputation  within  two  hours 
after  the  injury  calling  for  the  operation  had  been  received.  No 
one  pretending  to  do  surgical  work  in  small  towns  and  villages 
can  afford  to  be  without  such  an  outfit  as  before  described. 

The  results  of  surgical  work  done  in  North  Carolina  are  certainly 
surprising,  especially  to  one  who  has  not  taken  the  trouble  to 
look  up  the  statistics  on  the  subject.  Save  from  the  rarest  and 
most  difficult  operations  (and  at  the  hands  of  some  even  from 
these)  the  mortality  is  less  in  North  Carolina,  where  most  of 
us  are  denominated  Country  Surgeons  than  in  the  cities  at  the 
large  and  handsomely  furnished  hospitals.  Let  us  all  remem- 
ber that  McDowell  and  Sims  and  a  host  of  our  shining  lights 
achieved  their  best  results  and  acquired  their  begininggreatness 
as  country  surgeons.  There  are  all  over  our  beloved  State,  I 
am  pround  to  say,  a  great  many  medical  men  who  are  quietly 
and  unassumingly,  but  fearlessly  marching  successfully  along 
in  the  most  difficult  surgical  paths  relieving  the  distressed  with 
a  success  which,  if  it  were  known,  would  strike  wonder  to  the 
minds  of  the  out  side  world  and  really  even  to  themselves.  In 
no  state  in  the  union,  in  no  country  in  the  world  can  there  be 
found  such  men  as  these  North  Carolina  surgeons  are.  Like 
Capt.  Perry  they  can  very  truthfully  exclaim.  "We  have  met 
the  enemy  and  they  are  ours!"  Let  us  help  them,  therefore, 
and  encourage  them  in  every  possible  manner.  Remember  the 
test  is  not  always  in  the  distance.  In  this  as  in  all  things  else, 
let  us  as  far  as  practical  patronize  "home  industry,"  and  thus 
by  helping  them  help  and  honor  ourselves,  alv/ays  keeping  in 
view  that  grand  sentiment  that  the  true  surgeon  is  not  necessarily 
of  the  city  nor  the  guilded  mansion,  but  he  alone  is  worthy  of 
our  consideration  who  works  for  the  relief  of  suffering  humanity 
and  carves,  if  need  be,  through  the  greatest  difficulties  to  suc- 
cess. 


SOME   OBSERVATIONS   OM  THE   RADICAL  CURE   OF 

INGUINAL   HERNIA  WITH   REPORT  OF  AN 

UNUSUAL    CASE* 

By  J.  P.  MUNROE,  M.  D.,   Davidson,  N.  C. 


ALTHOUGH  herina  is  not  usually  regarded  a  serious  de- 
formity, yet  impairment  of  usefulness  does  not  occur 
so  often  from  any  other  anatomical  defect  as  from  this 
one.  No  condition  of  lite,  of  rank,  of  age  or  of  sex  is  exempt 
from  this  aflfliction,  and  when  the  viscera  protrude  through  the 
abdominal  walls  that  enclose  them,  the  condition  at  once  be- 
comes one  of  great  surgical  importance,  often  fraught  with 
gravest  danger  and  sometimes  with  serious  results. 

Nodisease,  perhaps,  requires  a  more  accurate  anatomical  knowl- 
edge for  its  successful  treatment  and  it  is  one  that  always  requires 
skill  and  often  promptness  on  the  part  of  the  surgeon.  The 
frequency  of  hernia  is  much  greater  than  is  gentrally  supposed. 

From  the  U.  S.  census  reports  in  1880,  it  was  found  that  out 
of  756,893  deaths,  1  in  600  was  from  hernia.  In  Philadelphia 
alone  450,000  trusses  are  manufactured  annually.  It  is  estimated 
that  between  }^  and  y^  ^^  ^^^  human  race  are  afflicted  with 
hernia.  In  tables  of  Dr.  Baxter,  Surgeon  General  U.  S.  A.,  we 
find  of  334,321  recruits  examined  for  the  army  16,901  were  reject- 
ed for  hernia,  this  being  j/i  of  total  rejections  for  all  causes.  Of 
these,  inguinal  herina  was  about  827  of  all  kinds,  and  right  in- 
guinal exceeded  all  the  rest  combined. 

The  anatomical  features  require  no  detailed  description  here, 
but  will  be  indicated  briefly  in  the  sterooptican  illustrations  to 
be  shown. 

The  usual  treatment,  from  time  immemorial  has  been  to  adjust 
a  properly  fitting  truss.  There  are  a  number  of  cases,  however, 
much  larger  than  is  generally  supposed,  that  should  be  operated 
upon.  The  operation  is  not  in  itself  a  serious  one,  and  if  done 
with  proper  care  usually  gives  good  results. 

It  is  not  my  purpose  to  burden  you  with  a  detailed  description 

of  any  one  of  the  many  operations  for  the  radical  cure,  but  to 

mention  one  or  two  points  of  importance  in  connection  with  the 

*Read  at  45th  Annual  Meeting  of  the  North  Carolina  Medical  Society,  Char- 
lotte, May  3,  1898. 


MUNROE-RADICAL  CURE  OP  INGUINAL  HERNIA.  407 

favorite  methods  and  to  report  an  interesting  case  operated 
upon. 

The  first  point  in  the  present  day  operation  is  to  establish  a 
new  inguinal  canal.  In  Bassini's  operation  this  is  done  by 
making  a  new  posterior  wall  for  the  canal  by  bringing  the  edge 
of  the  rectus,  the  internal  oblique  and  the  transversalis  down  to 
Poupart's  ligament  and  attaching  them  there  by  strong  ligatures. 

The  anterior  wall  is  formed  by  stitching  the  cut  edge  of  the 
external  oblique  to  Poupart's  ligament.  Halsteads  modification 
of  this  consists  in  including  the  external  oblique  in  the  stitches 
that  form  the  posterior  wall,  and  the  new  canal  with  the  cord 
will  then  lie  immediately  under  the  skin  and  superficial  fascia. 

The  other  point  of  importance  is  to  restore  the  obliquity  of 
the  canal. 

This  point  is  especially  emphasi-ced  by  Marcy  to  whom  I  am 
Indebted  for  many  valuable  suggestions.  The  internal  ring 
being  about  an  inch  and  a  half  above  and  to  the  outer  side  of 
the  external  opening,  the  abdominal  parietes  act  something 
like  a  valve  in  keepmg  the  canal  closed.  This  will  be  made 
clear  by  some  models  which  I  will  show. 

The  best  method  of  restoring  the  obliquity  of  the  canal, 
whether  it  is  located  according  to  Bassini  or  Halsteah  is  to  stitch 
from  below  upward  until  the  internal  ring  is  pushed  as  it  were, 
to  the  uppermost  limit  of  the  incision.  The  continuous  buried 
suture  may  be  used  or  the  interrupted,  which  I  think  gives 
equally  good  results. 

These  points  I  will  illustrate  and  also  show  a  case  of  which  I 
find  but  one  paralled  in  my  reading. 

J.  W.  F.  consulted  me  in  January  1897,  and  gave  the  follow- 
ing history.  "About  six  years  ago,  while  working  in  a  shop  in 
Louisville,  Ky.,  I  was  reaching  up  and  lifting  a  heavy  weight 
when  suddenly  I  felt  something  give  way  in  my  side.  Almost 
immediately  afterward  I  had  to  take  my  bed  and  an  immense, 
tender  swelling  developed  in  the  lower  part  of  my  right  side. 
My  physician  advised  me  to  go  to  my  home  in  Cincinnatti.  I 
did  so  and  went  with  the  expectation  of  being  carried  to  the 
cemetery  at  an  early  day. 

"An  examination  by  physicians  in  the  latter  city  led  to  the  con- 
clusion that  pus   was   present,  so  an  incision  was  made  into  the 


.qS  munroe-radical  ccre  of  inguinal  hernia. 

swelling  and  three  pints  of  pus  were  discharged.  Relief  was 
almost  immediate  and  I  made  a  rapid  recovery.  Two  years  ago 
a  tumor  developed  at  the  same  place.  My  physician  in  Florida 
opened  it  and  took  out  some  offensive  material  ^hich  he  thought 
was  the  cause  of  the  return  of  the  abscess.  Since  that  time  I 
have  had  a  severe  attack,  but  there  is  a  constant  enlargement  at 
the  site  of  this  cicatrix  and  it  frequently  becomes  considerably 
larger  and  very  tender." 

With  this  history  I  found  upon  examination  an  inguinal  hernia 
on  both  sides  easily  reduced,  but  on  the  right  side  at  the  point 
of  the  previous  incisions  a  swelling  remained  that  could  not  be 
entirely  reduced.  I  was  not  certain  whether  this  was  a  cicatricial 
thickening  of  tissue  or  an  imperfectly  reduced  herina.  I  advised 
an  opeartion,  but  as  it  was  not  convenient  for  him  to  have  it 
done  at  that  time,  I  endeavored  to  fit  him  with  a  truss.  After 
cartful  measurement  a  first  class  one  was  made  to  order,  but  It 
failed  to  give  relief,  and  indeed  was  so  painful  to  wear  that  he 
discarded  it  altogether  after  a  faithful  trial. 

In  August  1897,  he  consented  to  an  operation,  and  with  the 
assistance  of  Drs.  Mengies,  Johnson  and  Abernathy,  of  Hickory, 
I  operated. 

On  opening  the  inguinal  canal  I  found  in  addition  to  a  small 
hernial  sac  the  coecum  and  appendix  lying  on  the  cord  and 
closely  adherent  to  it.  The  appendix  extended  down  beside  the 
cord  and  it  took  careful  dissection  to  separate  the  two. 

After  removing  the  appendix  and  closing  the  opening  in  the 
appendix  I  broke  up  the  adhesions  of  the  coecum,  pushed  it  back 
into  the  abdominal  cavity  and  proceeded  as  in  an  ordinary  case 
of  ingainal  hernia. 

The  recovery  from  the  operation  was  rapid  and  satisfactory. 
One  interesting  feature  in  connection  with  his  convalescesce  was 
that  after  we  began  to  give  him  medicines  to  act  on  his  bowels 
he  passed  immense  quantities  of  hardened  faeces  and  among 
these  was  a  tooth  pick,  w'hich  he  remembered  having  swallowed 
two  month  before.  This  indicated  an  impaction  of  feces,  although 
there  had  been  no  previous  symptoms  especially  indicating  it. 

On  account  of  the  weakened  condition  of  the  parts  I  have  not 
been  very  hopeful  of  a  permanent  result,  but  a  letter  from  him 
last  week  informs  me  he  is  still  perfectly  wrll.  I  will  now  illus 
trate  the  points  which  I  have  emphasized. 


"A  SHAWL  PIN  IX  THE  TRACHEA." 
Bv  K.  P.  Battle,  M.  D.,  Raleigh,  N.  C. 


ON  March  nth,  Miss  S.  H.,  i6  years  of  age,  while  holding  in 
her  mouth  a  sharp  pointed  steel  shawl  pin,  said  to  be  two 
inches  in  length,  allowed  it  to  slip  down  her  throat.  A 
bystander  at  once  looking  into  her  mouth  caught  sight  of  the 
pointed  end  of  the  object  in  the  pharynx.  Dr.  G.  A.  Renn  was 
called,  but  the  pin  had  disappeared  and  he  brought  the  patient 
to  me.  Examination  with  a  throat  mirror  failed  to  reveal  it, 
though  it  must  be  said  that  the  trachea  could  be  seen  only  for  a 
short  distance  below  the  cords.  There  was  no  cough  and  the 
respiration  was  easy  and  unimpeded.  There  had  been  such  an 
absence  of  strangling  sensation  that  she  thought  she  had  swal- 
lowed it  and  we  were  disposed  to  agree  with  her.  For  some 
days  the  only  symptoms  were  a  very  slight  and  infrequent  cough, 
but  after  a  pronounced  spell  of  coughing  and  a  show  of  blood 
stained  sputum,  Dr.  Renn  took  the  patient  to  Chapel  Hill,  in 
hope  of  locating  the  pin  by  the  use  of  the  Roentgen  rays.  Prof. 
Gore  and  Dr.  Whitehead  were  very  kind  in  their  attention  to 
the  case,  but  the  University's  present  powerful  apparatus  had  not 
been  put  in  service,  and  the  only  information  obtained  by  the 
old  machine  was  that  there  was  no  foreign  body  above  the  level 
of  the  sternum.  So  quiec  was  the  breathing  at  this  time  that 
the  opinion  was  again  expressed  that  the  body  had  probably 
been  swallowed. 

Several  days  passed  without  accident  until  the  patient  coughed 
the  pin  into  the  throat,  as  she  expressed  it,  where  she  could  feel 
it  for  several  minutes,  till  it  dropped  back  to  its  old  position.  I 
did  not  learn  of  this  until  the  termination  of  the  case. 

A  week  later  and  22  days  after  the  accident  she  had  a  violent 
paroxysm  of  coughing,  and  when  brought  to  me  was  still  in  con- 
siderable distress.  I  found  the  pin  lodged  in  the  larynx,  with 
the  head  below  the  cords,  and  the  point  fixed  in  the  epiglottis 
near  its  center.  This  cartilage,  while  not  in  the  infantile  posi- 
tion was  less  erect  and  over- hung  the  larynx  to  a  greater  extent 
than  is  commonly  seen  in   the   adult.      After  spraying  with  co- 

*Read  at  the  Annual  Meeting  of  the  North  Carolina  Medical  Society,  Char- 
lotte,  May  3,  1S9S. 


^lO  BATTLE— A  SHAWL  PIN  IN  THE  TRACHEA. 

caine  I  grasped  the  only  available  part  of  the  pin,  the  shank, 
with  Seller's  flexible  tube  thioat  forceps  and  made  downward 
pressure  in  the  hoping  of  freeing  the  point,  preparatorj'  to  an 
attempt  to  get  it  to  pass  the  epiglottis;  but  I  could  not  afford 
afterwards  to  loosen  the  firm  grip  of  the  forceps  in  an  effort  to 
get  a  more  favorable  hold,  for  fear  of  the  pin  slipping  down  the 
trachea  again.  A  steady  pull  was  now  made,  but  the  pin  did 
not  seem  to  budge.  The  next  inspection  showed  that  it  had 
pierced  the  epiglottis.  The  point  could  be  seen  protruding  fnm 
the  middle  of  its  upper  surface.  I  then  caught  hold  of  the  point 
and  pulled  it  through  as  far  as  the  head.  It  was  now  surely  out 
of  the  larynx  and  the  greatest  danger  was  over.  The  patient 
was  by  no  means  yet  relieved  of  its  presence,  but  I  could  safely 
pause  and  discuss  the  next  step  with  Dr.  Renn  who  was  with 
me.  The  pin  was  too  long  to  be  turned,  its  upper  part  was  in 
plain  view  in  the  fauces  when  the  tongue  was  depressed,  and  we 
decided  to  cut  it  in  two  and  remove  the  point  half  first.  We 
were  not  provided,  however,  with  an  instrument  that  would  cut 
such  a  stout  steel  wire  in  such  a  position.  A  strong  pointed  nosed 
wire  cutter,  acting  on  the  scissor  principle  was  borrowed  from 
a  jeweller,  and  proving  too  short,  was  lengthened  temporarily 
by  the  insertion  of  the  handles  into  two  metal  tubes  of  suitable 
size.  With  this  instrument  and  an  ordinary  pair  of  forceps,  the 
steel  was  easily  snipped  in   two  and  the  upper  half  taken  out. 

To  extract  the  remaining  half  of  the  pin,  I  used  the  ideal  in- 
strument for  the  purpose,  a  Seller  tube  forceps  in  which  the  nip- 
per part  consisted  of  two  hemispherical  steel  cups.  When  the 
cups  were  passed  behind  the  epiglottis  and  closed  over  the  pin's 
head,  slipping  was  an  impossibility,  and  the  shank,  now  short 
enough,  was  easily  reversed  and  the  whole  removed  without 
difficulty.  The  young  lady  certainly  deserved  the  happiness  of 
the  relief,  for  she  had  endured  the  manipulations  with  rare  for- 
titude. All  irritation  rapidly  subsided  and  perfect  health  was 
soon  restored. 

When  examined  the  pin  proved  to  be  one  and  three  quarter 
inches  in  length,  of  steel,  quite  sharp,  with  a  vulcanite  head  a 
quarter  of  an  inch  in  diameter.  Owing  to  its  originally  high 
polish  it  had  rusted  very  little^ 

This  case  presents  an  interesting  study  in   the  matter  of  the 


BATTLE- A  SHAWL  PIN  IN  THE  TRACHEA. 

41  I 

measure  ot  success  attained  by  the  natural  efforts  of  the  organism 
to  relieve  itself.  That  the  pin  should  have  gotten  into  the  throat 
at  all  was  due,  in  part,  to  a  failure  of  nature  to  afford  the  body 
protection,  for  though  it  is  a  dangerous  practice  to  put  such 
things  into  the  mouth,  it  cannot  be  said,  in  view  of  the  habit  of 
babies  in  this  respect,  that  it  was  unnatural.  Yet  if  the  involun- 
tary reflex  powers  of  the  pharynx  and  larynx  failed  to  stop  its 
passage  it  may  be  u-ged  in  their  behall  that  they  were  not 
designed  to  deal  with  bodies  of  such  a  shape.  Be  this  as  it  may 
the  system  made  a  remarkable  effort  to  retrieve  the  mistake.  The 
head  of  the  pin  evidently  rested  most  of  the  time  on  the  bifurca- 
tion of  the  trachea.  Several  fruitless  attempts  were  made  to 
eject  the  intruder  but  the  point,  directed  upwaids,  would  catch 
in  the  mucous  membrane,  as  shown  by  the  cough  and  the  blood 
stained  expectoration.  Once  a  fair  start  was  made  and  the 
larynx  was  reached,  but  failure  again  resulted  and  another  effort 
must  be  made.  Finally  the  object  was  again  shot  towards  the 
outlet,  the  point,  being  doubtless  guided  by  a  portion  of  the  blast 
of  air  escaping  past  the  head,  found  the  chink  of  the  glottis,  got 
beyond  the  cords,  fastened  itself  in  the  over  hanging  epiglottis, 
the  nearest  possible  approach  to  complete  victory  was  attained 
and  extraction  by  the  natural  passages  was  made  practicable. 

The  general  statement  may  be  made  that  when  the  body  is 
contending  against  disease  or  the  result  of  accident,  and  the 
issue  is  vital,  the  most  important  and  frequently  the  most  diffi- 
cult question  for  the  surgeon's  decision  is  the  selection  of  the 
time  when  trust  in  nature  should  be  abandoned  and  active  inter- 
ference begun.  The  accumulated  experience  of  the  world  as 
time  goes  on  will  help  in  the  laying  down  of  more  and  more 
definite  rules  for  our  guidance.  In  the  present  instance  if  we 
had  sooner  known  with  certainty,  what  the  position  of  the  object 
was,  an  awkward  problem  would  have  presented  itself.  The 
chance  of  a  successful  removal  through  a  tracheal  opening  of  a 
pin  of  this  kind,  situated  head  downward  at  the  bottom  of  the 
trachea,  seems  so  desperate  that  this  case  is  reported  to  put  on 
record  how  much  is  possible  for  unaided  nature  to  accomplish. 

IMSCUSSION. 

Z>r.  Galloway. — I  know  of  one  or  two  interesting  cases  some- 
what on  the  same  line.      In   the   late    meeting  at   Atlanta,  I   re 


^j2  BATTLE— A  SHAWL  PIN  IN  THE  TRACHEA. 

lated  the  case  of  a  child,  or  ritherasmall  boy,  who  was  brought 
to  my  office  one  night,  who  hud  a  sandspur  in  his  throat.  I  ex- 
amined the  throat  carefully,  Mr.  President,  and  found  a  sand- 
spur  lodged  at  the  bottom  of  the  vocal  cord.  I  used  a  4  per 
cent,  solution  of  cocaine,  and  endeavored  to  extract  it.  I  had 
no  difficulty  in  getting  to  it  with  an  ordinary  laryngeal  forceps, 
but  everv  time  I  got  down  to  it,  there  was  such  retching  I  had 
to  stop.  The  boy  previously  had  vomited  and  had  a, good  deal 
of  trouble.  I  at  last  succeeded  in  getting  hold  of  the  sandspur, 
and  just  at  that  moment  the  boy  vomited,  and  up  came  the 
sandspur. 

Dr.  Payne. — I  am  much  interested  in  Dr.  Battle's  paper,  be- 
cause it  opens  up  a  question  which  has  been  considered  settled, 
as  to  how  long  after  a  foreign  body  has  gotten  into  the  trachea, 
it  is  safe  to  do  tracheotomy  for  removal.  According  to  recog- 
nized authorities,  when  a  foreign  body  is  retained  for  a  number 
of  days,  it  is  safer  to  await  nature's  efforts  than  it  is  to  do  tra- 
cheotomy, but  I  am  convinced  that  this  chapter  will  have  to  be 
re-written.  I  had  a  case  recently  which  leads  me  to  believe  that 
even  m  the  last  stages  after  actual  catarrh  or  pneumonia  has  re- 
sulted, good  results  will  follow  tracheotomy.  The  patient  was 
referred  to  me  by  Dr.  Whitehead  from  Rocky  Mount.  The  child 
had  a  grain  of  corn  in  the  trachea.  There  were  active  catarahal 
and  pneumonic  symptoms,  the  result,  I  thought,  of  the  deten- 
tion of  chis  grain  of  corn  in  the  trachea.  It  could  be  heard  oc- 
cisionally  moving  up  and  down.  I  looked  up  all  the  surgical 
authorities,  and  in  spite  of  the  fact  that  they  all  advised  against 
the  operation,  I  did  tracheotomy,  the  grain  was  expelled,  the 
child  recovered.  Dr.  Senn,  who  happened  to  be  in  Norfolk  at 
the  time,  thought  the  action'  I  had  taken  was  proper,  and  said 
that  he  was  convinced  that  the  whole  teaching  on  the  subject 
was  wrong.  Coming  from  such  high  authority  as  that,  and 
owing  to  the  fact  that  I  did  it,  I  vvould  like  to  have  the  expres- 
sion ot  the  Society  as  to  the  propriety  of  operating  in  these  cases. 

Dr.  Carr: — Reported  a  case  in  which  he  operated  to  remove 
a  grain  of  corn  the  day  after  it  got  into  the  trachea.  When  the 
trachea  was  opened  the  corn  was  expelled.  In  another  case  he 
operated  for  a  cocklebur  which  had  been  in  the  trachea  over  a 
month,  and  the  patient  died.  He  advisesd  against  operating 
unless  there  were  bad  symptoms. 

Dr.  Galloway: — Reported  a  second  case  which  he  saw  in 
consultation.  A  two  year  old  child  had  gotten  a  peanut  in  the 
trachea  six  days  before.  When  he  saw  the  child  it  did  not 
seem  to  be  in  any  distress,  though  the  mother  stated  that  it  had 
been,  though  for  the  last  day  or  two  it  seemed  to  be  getting 
along  very  nicely.  He  advised  against  an  operation  from  the 
simple  fact  that  he  was  decidedly  of  the  opinion  that  the  peanut 
was  low  down,  possibly  beyond  the  bifurcation,  and  also  on  the 


WAY— EXPERT  MEDICAL  WITNESSES.  .  .  . 

ground  that  the  child  was  doing  ve-y  well.  If  at  any  time  it 
should  get  dangerous,  then  there  would  be  sufficient  opportunity 
to  perform  the  operation.  It  went  on  very  nicely  for  about  three 
weeks,  when  after  a  coughing  spell,  it  coughed  up  one  half  of 
the  peanut. 

Dr.  Faison: — Reported  a  case  in  which  a  grain  of  corn  was 
expelled  from  the  trachea  on  the  boy  tripping  and  falling  across 
a  potato  ridge. 

Dr.  Costener: — Exhibited  a  thimble  which  was  removed  from 
the  trachea.  It  had  lodged  at  the  bifurcation  of  the  trachea, 
and  created  a  great  deal  of  infiamation  about  the  bronchi;  also 
the  child  could  not  swallow,  but  had  to  be  fed  by  a  tube,  and 
this  was  kept  up  for  six  weeks. 


EXPERT  MEDICAL  WITNESSES:    WHAT  IS  THE  CAUSE 
OF  THE  SEEMING  DISREPUTE  IN  WHICH  THEIR 
TESTIMONY  IS  HELD  IN  CERTAIN  RECENT 
CASES  IN    THE   COURTS?      OBSERVA- 
TIONS FROM  THE  STANDPOINT  OF 
THE  COUNTRY  DOCTOR.* 

Bv  J.  Howell  Way,  M.  D.,  Waynesville,  N.  C. 


THE  criticisms  given  by  the  daily  press  of  the  country  on  the 
expert  testimony  in  the  recent  noted  cases  in  the  courts 
where  medical  gentlemen,  prominent  in  the  profession, 
occupying  positions  of  great  responsibility  to  the  profession  as 
teachers  and  as  consultants,  to  the  public  in  that  from  the  position 
accorded  them  by  the  profession,  they  become  men  whose  words 
weigh  much  with  the  laity,  have  evoked  considerable  attention 
from  the  writing  part  of  the  profession.  Some  of  these  articles, 
in  common  with  all  doctors  who  feel  a  lively  interest  in  what- 
ever pertains  to  the  welfare  of  our  honored  guild,  I  have  read 
with  the  greatest  interest,  feeling  that  out  of  the  discussion 
would  be  evolved  valuable  suggestions. 

For  quite  a  number  of  years  past  the  idea  of  an  "Expert  Com- 
mission," to  be  created  by  law,  and  to  which  all  questions  of  a 

*Read  at  the  Annual  Meeting  of  the  North  Carolina  Medical  Society,  Char- 
lotte, May  3,  1898. 


.  ,  .  WAY-EXPERT  MEDICAL  WITNESSES. 

A' A 

medical    nature    arising    in    the   courts   would    be   referred    for 
examination  and  solution,    has  been  periodically   sprung   on    a 
suffering  profession.      Recently   it   is   noted    that   the  same  sug- 
gestion has  been  going  the  rounds  of  the  medical  press,    and    is 
seemingl)'  the  more  favored    solution   of  a  questi&vexaie.     For  a 
Republican  form  of  government,  it  rs  more  than   probable  that 
there  are  already  too  many  men  in    "commission"  to  do  this  or 
that  particular  thing,  which  the  people  could  do  for  themselves, 
in  their  own  Mme  and  their  own  way,  and  perhaps  equally  well. 
Yet  this  idea  of  a  commission  advisory  to  the  court,  seems  to  be 
the  favored  solution — -the  main  remedy  offered  on  various  hands 
for  the  abatement  of  what  is  claimed  as  the  source  of  great  danger 
to  the  future  character  and   influence  of  the   profession.      It  is 
difficult  to  see,  however,  how  the  proposed  scheme  could,    if   it 
were  practicable   to  carry  it   into   effect,    possibly   prevent  the 
troubles  of  which  the  doctors  complain   in   regard  to  the  opera- 
tion of  the  present  system.      Take   for    illustration    the   Carlyle 
Harris  case  in  New  York  a  few  years  since,  or  the   more   recent 
Leutgert  case  in  Chicago;  in  each  case  we  have  some  of  the  most 
prominent  medical  gentlemen  in   their   respective   cities,    gomg 
on  the  witness  stand  and  flatly  contradicting   each   other  about 
scientific  questions  as  to  facts.      Now  if  as  generally  understood, 
science  knows  no  variation  ;  that  it  consists  of  certain  fixed  laws, 
these  gentlemen  must  have  known  what  part  of  their  testimony 
was  scientific  facts  and  what  part  was  opinion,  conjecture   or 
possibility.     Would  medical  men  be  more  inclined  to  agree  with 
one  anothei  before  a  commission  than  in  the  glare  of  the  public's 
gaze  in  the  open  courts?  Doubted.      But  it  is  assumed  that  the 
idea  of  a  commission  would  involve  the  submission  of  medical 
points  involved  in  medico-legal  questions  arising  in   the  courts, 
to  only  men  of  special  and    profound    knowledge.      Just    how 
this  would   make  the  matter  better,  except  for  the  favored  few 
who  constituted  the  commission,  cannot  in  the  present   light  be 
shown.      The  very  prominent  experts  are  the  ones  who  (and  it  is 
said  m  all  kindness  of  these  gentlemen  for  we  all  have  the  pro- 
foundest  respect  and  admiration  for  those  who  succeed  in  mak- 
ing reputations  for  themselves  in  medicine)  are  constantly  get- 
ting into  the  newaspapers  with   the   odium   of   the  court  house 
"wranglings  of  the  doctors"  and  resultant    criticisms    attached 


WAY-EXPERT  MEDICAL,  WIT^^E3SK3  ^^- 

£0  them,  and  through  them  to  the  profession  for  which  they  are 
assumed  to  stand.  It  is  my  candid  opinion  that  in  the  smaller 
cities  of  the  country  and  the  rural  districts  in  general,  where 
there  are  fewer  or  no  ^'professors"  of-medicine,  that  the  matter  of 
expert  testimony  is  developed  in  the  courts  with  far  less  friction 
between  the  opposing  sides  and  with  a  corresponding  degree  of 
credit  to  the  doctors.  This  statement  is  made  advisedly.  In 
the  past  twelve  years  it  has  occisionly  fallen  to  the  lot  of  the 
writer  to  appear  in  the  courts  of  his  own  and  adjoining  counties 
in  the  capacity  of  an  expert  medical  witness,  and  he  here  records 
his  court  experiences  as  among  the  pleasures  of  his  professional 
life.  But  certain  rules  have  always  been  scrupulously  followed  : 
In  the  first  place  the  witness  has  never  bargained  for  or  received 
a  fee  from  either  side  prior  to  his  appearance  in  the  courtroom. 
His  cases  have  been  carefully  studied  before-hand,  and  after  con- 
ferring with  the  other  medical  men  who  were  to  appear  in  the 
case  and  adjusting  any  grave  differences  which  might  on  first  view 
have  existed  between  them,  he  has  gone  on  the  witness  stand  and 
told  in  the  plainest,  simplest  language  possible,  what  he  knew 
of  the  case,  strictly  avoiding  as  he  would  an  upas  tree  all  pro- 
fessional technicalities.  When  my  opinion  is  asked  as  to  a  ques- 
tion which  I  know  is  unsettled  in  the  minds  of  the  profession, 
or  in  controversy,  I  invariably  after  a  word  of  explanation,  con- 
fess my  ignorance.  And  right  here,  I  believe  lies  the  trouble 
with  so  many  of  the  modern  metropolitan  medical  experts — they 
know  too  much!  Too  vast  an  amount  of  professorial,  profess- 
ional, or  personal  dignity  at  stake  for  the  expert  to  say  candidly, 
"I  don't  know, "  And  the  clever  attorneys  fully  appreciating 
this  fact  play  on  the  doctor's  weakness,  and  when  the  proper 
time  arrives  the  expert's  testimony  and  his  foibles  are  shrewdly 
dissected  before  the  jury.  And  the  lawer  only  does  what  he 
ought  to  from  the  stand-point  of  his  employer.  I  have  no  criti- 
cisms to  make  here  of  the  attorneys.  They  can  legitimately 
prey  on  any  man  who  opens  the  way.  My  observation  is,  that 
as  a  rule,  medical  men  are  themselves  responsible  for  the  ridicule 
theii  evidence  is  occasionally  subjected  to  in  the  court  room. 

On  every  hand  the  fact  is  appreciated  that  marked  advances 
have  been  made  along  the  lines  of  human  activity  in  the  past  two 
or  three  decades ;  in  none  has  there  been  a  greater  degree  of  ac- 


.  j^  WAY— EXPERT  MP^DICAL  WITNESSES. 

tivity  displayed,  or  greater  results  accomplished  than  in  the 
field  of  scientific  medicine.  Much  real  advance  has  been  made, 
many  valuable  discoveries  fraught  with  blessings  to  humanity 
have  been  brought  to.  the  light  of  our  knowledge  through  the 
restless  energies  of  thousands  of  indefatigable  workers  in  the 
field  of  modern  medicine.  Far  be  it  from  the  intention  of  the 
writer  to  cast  one  iota  of  obloquy  upon  the  good  work  of  our 
honored  profession  in  detracting  from  the-  splendid  record  of 
progress  in  recent  years;  but,  the  practical  fact  remains,  that 
every  new  idea  has  not  as  some  of  our  brothers  would  have  us 
believe,  been  an  improvement  on  the  old  or  an  advancement  to 
the  front.  While  the  general  tendency  of  our  professional  life  in 
scientific  work  has  been  distinctly  and  emphatically,  forward 
and  upward  to  the  eternal  light  which  illumes  all  things,  yet  it 
is  to  be  remembered,  to  borrow  the  figure  of  another,  that  in 
our  evolution  some  of  the  branches  of  the  tree  of  progress  grow 
upward  and  to  the  light,  some  grow  downward  soon  finding 
their  terminal  buds,  some  wither  and  die,  and — yet  it  takes  all 
to  make  the  tree;  so  as  honest  men  we  must  admit  that  while 
substantial  advance  is  made  every  day,  we  are  even  now  abso- 
lutely in  the  dark  as  regards  the  correct  solution  of  countless 
problems  in  the  mathematics  of  medicine. 

A  distinguished  savant  makes  an  experiment  today  which  he 
hopes  will  lead  to  something;  the  next  day  the  details  of  the  ex- 
periment are  heralded  the  earth  over  a  most  w^onderful  demon- 
stration of  established  facts.  The  day  following,  the  same 
scientist,  or  hundreds  of  co-workers  in  the  fields  of  science,  re- 
peats the  experiment  and  finds  that  a  certain  element  of  error, 
not  calculated  for  in  the  original  experiment,  renders  null  and 
void  the  assumed  conclusions  of  he  first  day.  The  general 
public  are  not  informed  of  this  however.  Later  they  find  out 
the  facts  and  then  their  respect  for  scientific  expounders  and 
their  science  is  proportionately  lessened.  Witness  tuberculin: 
Call  to  mind  the  excited  throngs,  both  of  students  and  aflilicted 
who  flocked  to  Berlin  during  the  few  months  following  the  an- 
nouncement of  Koch's  discovery.  To  bring  it  nearer  home, 
look  at  the  history  of  vaginal  injections  during  and  after  labor. 
Only  a  few  years  since  it  was  gravely  announced  by  those  high 
in  authority  in  the   medical   world,    that   no  woman   should    be 


WAY-EXPERT  MEDICAL  WITNESSES 

perflated   to   bring  forth   off-spring   without  her  genitals  being 
rubbed,  scrubbed,  scraped  and  injected  with  strong  solutions  of 
toxic  drugs  a  certain  number  of  times  (the  details  of  the  proces-^ 
almost  suggested  Hahnemann's  directions  in  his  '^organon"  for 
preparing  a  -potency!"),  then  a  -pad"  of  the   far-famed    spices 
of  the  Onent  was  to  be  placed  at  the  vaginal  entrance  to  frighten 
timorous  microbes  away.     Such  was  the  dictum  that  with  -pro- 
fessional" sanction  went  out  over  the  country;   notwithstanding 
this,  there  were  intellectual  -giants  in  those  days,"   who   dared 
to  reason  for  themselves  and  questioning  said,.is  not  this  a  violent 
perversion  of  nature's  methods?    And  while  the  many  of  the  pro- 
fession were  for  the  time  swayed  by  the  injection    idea   (largely 
because  it  was  -new"  and  -the  latest,")  there  was  a  very  large 
portion  of  the  profession  who  rejected  it  as   illogical  treatment. 
On  my  desk  today  lies  an  ably  written  article  recently  published, 
from  the  pen  of  an  acknowledged  authority  on  obstetric-1  science 
enveighing  against  the  practice  of   using  vaginal   injections   in 
labor  and  criticising  the  monthly  nurse   for   her  disposition    to 
use  the  douche,  whether  so  advised  by  the  attending   physician 
or  not.      Yet  this  article  does  not  give  a   hint   as   to    where    the 
afore-mentioned  nurse  was  indoctrinated  with  the   supreme    ne- 
cessity of  vaginal  injections  in    labor.      One  of  the   first   things 
we  are  taught  as  students  of  medicine  from   the  chair  of  thera- 
peutics is  to,  if  possible,  ascertain  and  then  remove  the  cause. 

Nothing  in  my  professional  work  has  interested  me  more  than 
to  trace,  and  when  possible  ascertain,  the  origin  of  the  oft-times 
(but  not  always),  absured  or  foolish  ideas  advanced  by  the  laity 
as  regards  the  nature  of  treatment  of  disease.  I  do  not  say  the 
ignorant  laity,  for  my  observation  has  been  that  the  chief  differ 
ence  between  the  ignorant  and  the  intelligent  laity  is  that  the 
ignorant  laity  is  just  a  generation  or  so  behind  the  intelligent 
laity  in— in  what?  In  reflecting,  with  some  modification  perhaps, 
what  was  set  forth  at  some  time  as  gospel  medical  truth  by  the 
profession,  or  part  of  it.  Hence  theacconaplished  author  above 
referred  to  would  have  don'e  us  all  a  kindness  and  performed  a 
legitimate  penance  had  he  simply  stated  where  the  nurse  imbibed 
her  dreadful  notions. 

But  this  by  the  way:     The  idea  of  the  writer  is  to  direct  at-  * 
tention  to  what  he  believes  to  be  one   of   the,    if  not   the  chief. 


.  jg  WAY-EXPERT  MEDICAL  WITNESSES. 

causes  of  the  threatened  disrepute  into  which  it  is  gravely  as- 
serted expert  testimony  is  in  danger  of  falling,  and  incidentally  to 
note  that  the  general,  everyday  practitioner  of  medicine  cannot 
afford  to  endorse  such  ideas  as  tend  to  produce  the  belief  that 
relief  is  to  be  found  in  putting  "in  commission"  certain  gentle- 
men who  will  attend  to  the  elucidation  of  medico-legal  questions 
for  the  profession  and  for  the  courts.  The  severest  wrangling 
over  medical  cases  in  the  courts  today  is  when  gentlemen  of  the 
class  from  which  it  is  proposed  that  the  commission  be  created, 
appear  in  the  courts  on  opposing  sides. 

To  get  at  the  cause  if  possible,  of  the  trouble  is  our  first  duty ; 
then  if  possible,  remove  it.  One  of  the  dangers  which  an 
expert,  and  the  more  reputation  he  has  to  sustain  the  greater 
the  danger,  is  likely  to  encounter,  is  that  of  knowing  too  much. 
If  medical  men  were  as  ready  to  admit  in  the  court  room  their  real 
ignorance  of  many  things  as  they  are  in  the  privacy  of  the  con- 
sultation room,  there  would  be  far  less  wrangling  of  the  experts, 
with  the  result  that  much  more  respect  would  be  entertained  for 
their  evidence.  Doctors  are  oft-times,  rather  than  make  a  frank 
confession  of  ignorance,  tempted  to  build  upon  one  known  fact 
in  medicine,  coupled  with  a  half  a  dozen  may-bes  or  conjunctures, 
a  theory  which  to  be  honest  with  themselves  they  may  believe, 
but  do  not  and  cannot  know.  This  theory  is  then  elaborated 
and  given  to  the  court  as  an  exposition  of  the  teachings  of 
medical  science.  Now  this  is  all  wrong,  but  we  do  not  need  to 
invoke  the  aid  of  legislation  to  set  such  things  to  right,  but 
rather  the  exercise  of  common  horse  sense.  It  is  a  family  affair 
so  to  spe-.k,  and  should  be  settled  by  those  most  interested.  In 
every  case  where  medical  witnesses  are  summoned,  if  these  same 
medical  experts  will  get  together  and  calmly  and  critically  re- 
view the  evidence  of  each  man,  throwing  out  what  is  only  con- 
jecture or  rests  on  insufficient  scientific  foundation,  leaving 
to  be  given  out  what  is  generally  accepted  by  the  profession  as 
known  facts;  then  later  when  on  the  witness  stand,  with  an  eye 
more  to  trueness  to  professional  honor  than  to  being  the  plaint- 
iff's or  defendant's  "expert,"  tell  what  he  knows  and  resist  the 
allurement  of  keen-witted  counsel  to  extract  information  which 
he  does  not  possess,  that  man  will  retire  from  the  stand  con- 
scious of  having  maintained  his  self-respect.      He  will  also  merit 


WAY-EXPERT  MEDICAL  WITNESSES.  ,,„ 

and  receive  that  of  the  court.  A  proper  appreciation  of  this 
ought  to  make  it  possible  to  be  put  into  operation  by  the  masses  of 
the  profession  who  have  regard  for  their  professional  honor.  As 
to  the  professional  experts  it  is  hard  to  say  what  they  would  or 
will  do.  Apply  the  method  herein  suggested  to  the  practice  of 
medical  jurisprudence  in  the  courts  and  it  is  not  likely  that  self- 
respecting  medical  men  will,  after  carefully  studying  the  case 
together,  go  into  the  court  room  and  exhibit  the  spectacle  pre- 
sented in  the  recent  Leutgert  case  where,  given  a  small  fragment 
of  the  upper  extremity  of  a  femur,  one  gentleman  swore  posi- 
tively that  in  his  opinion  it  was  the  femur  of  a  human  female;  the 
other  with  equal  positivity  asserted  it  to  be  the  femur  of  a  hog. 
On  the  day  following  the  astute  att)rney  produced  in  court 
bones  known  to  have  been  derived  from  a  chimpanzee  which 
bones  were  identified  by  the  experts  as  human.  laiagine  the 
humiliating  position  of  these  gentlemen;  amusing  to  the  spec- 
tators, and  disgustine  to  every  plam,  common  sense  doctor  who 
followed  the  testimony.  Both  medical  men  should  have  testified 
that  the  bit  of  bone  was  the  upper  end  of  the  thigh-bone  of  an 
animal  which  brought  forth  its  young  alive,  i.  e.,  a  mammalian 
and  mentioned  some  of  the  more  common  animals  from  which 
the  bone  might  have  come.  They  should  have  positively  stated 
that  with  the  very  short  fragment  exhibited,  it  was  impossible 
to  say  it  was  or  was  not  a  human  bone.  (After  days  of  wrangling 
this  is  really  what  their  con-joint  testimony  amountee  to!)  This 
course  would  have  saved  their  credit  and  that  of  the  profession 
in  general  which  is  always  affected  more  or  less  by  the  actions 
of  its  members.  It  is  true  this  would  have  been  indefinate,  but 
(as  the  sequel  proved)  it  would  have  been  the  truth,  and  when 
told  in  a  dignified  professional  way  would  have  enabled  the 
doctors  to  have  retired  from  the  stand  with  more  honor  than 
attached  to  the  experts  whose  perhaps  too  ample  ^^<?  led  them  to 
know  too  much.  These  gentlemen  were  acknowledged  expert 
comparative  anatomists.  The  blunder  as  to  the  chimpanzee 
bones,  the  positive  divergence  of  opinion  as  to  the  source  of  the 
piece  of  the  femur  exhibited  to  them,  presuming  as  we  do  that 
the  experts  told  what  they  believed  to  be  the  truth,  proves 
conclusively,  that  comparative  anatomy  is  not  yet  a  sufficiently 
exact   science    to   enable   one,  from  only  a  small  part  of  a  bone. 


•  20  WAY— EXPEKT  MEDICAL  WITNESSES. 

(unless  it  should  be  a  part  possessing  some  very  special  or  pro- 
nounced process  or  foramina,  etc.,  rendering  its  character  un- 
mistakable), to  positively  identify  it  as  coming  from  the  body  of 
a  certain  animal.  Now  to  candidly  admit  this  fact  need  bring 
no  discredit  to  our  profession  or  to  the  individual  doctor  so 
testifying.  We  are  not  expected  to  know  everything  in  the 
court  bouse,  whatever  may  be  the  demands  made  on  us  in  the 
sickroni.  A  clear  recognition  of  this  fact  on  the  part  of  the 
profession,  coupled  with  a  sincere  regard  for  stating  when  on 
the  witness  stand  only  what  are  known  to  be  established  facts, 
and  a  disposition  not  to  allow  the  erudite  attorneys  to  lead  him 
to  becon^e  a  partisan,  will  I  think  contribute  very  greatly  to  ad- 
vance 'the  esteem  in  which  medical  expert  testimony  is  held 
by  the  courts  and  by  the  general  public.  These  remarks,  as 
elsewhere  noted,  are  intended  to  apply  more  particularly  to  the 
general  masses  of  the  profession — the  practical  men  who  help 
nature  save  and  prolong  the  lives  of  our  fellow  creatures. 

As  for  the  professional  "experts,"  if  they  want  the  legislatures 
of  the  country  to  look  after  them  with  disciplina-y  eye,  I  really 
see  no  objection(?)  to  their  being  put  "in  commission,"  or  else- 
where. Seriously,  can  not  these  gentlemen,  so  very  clamorous 
for  special  legislation,  read  the  "signs  of  the  times"  better  than 
to  not  see  that  the  very  fact  of  their  more  or  less  valuable  ser- 
vice being  had  by  either  side  in  any  case,  carries  with  it  the 
death  warrant  of  the  call  for  professional  experts  in  the  courts 
of  justice?  The  American  people  are  a  very  practical  type,  and 
a  few  more  exhibitions  of  medical  experts,  a  ala  Leutgert  style, 
will  make  the  masses  feel  that  "these  experts  are  all  frauds" — 
exit  the  professional  expert ! ! 

But  long  after  this  ^(T/iz/jf  shall  have  for  remembrance  only  a 
"trace  of  mould"  in  the  sociologic  lawyers  of  the  past,  there  will 
be  more  or  less  frequent  calls  for  some  plain,  practical  observa- 
tions on  medical  questions  coming  before  them,  from  the  plain 
every-day,  common-sense  doctors  who  have  opinions  only  about 
the  things  of  which  they  know  (and  are  not  embarrassed  at  not 
knowing  all  things!),  and  not  based  on  what  might,  could, 
would,  should,  or  did  not  happen.  Speed  the  day!  But  evolu- 
tion, sociologic  as  material,  is  slow. 


IJAVIDSON-INCISION  OF  GALL  BLADDKU  ETC!.  ^  [ 

]>ISLUSSU)X. 

Dr.  Murphy: — I  suppose  1  must  say  somelliiiig  after  having 
had  the  paper  read.  1  am  very  much  gratified  at  the  position 
the  doctor  took  in  his  paper.  There  has  been  appointed  in 
several  States  recently  either  by  the  Legislature  or  by  the  court, 
a  commission  to  assist  the  court  in  all  questions  requiring  expert 
testimony,  whether  physicians,  mechanics,  or  whatever  they 
might  be.  I  have  seen  some  severe  critisisms  on  this  course,  and 
do  not  know  how  satisfactory  it  is  but  I  do  know  that  the  sug- 
gestion the  doctor  makes,  that  the  experts  should  hold  a  con- 
sultation, has  been  tried  and  worked  admirably  in  one  case.  It 
was  rather  a  celebrated  case,  I  don't  think  now  of  the  name  of 
the  defendant,  but  the  man  killed  the  cashier  of  a  bank  and 
escaped  in  broad  open  day  time.  The  defence  set  up  the  plea 
of  insanity.  There  was  a  large  array  of  witnesses  on  both  sides, 
some  of  the  most  distinguished  men  in  New  England.  The  ex- 
perts for  the  defence  had  the  defendant  first.  They  seemed  to 
have  posted  him  ;  he  knew  a  great  deal  about  the  science  of  in- 
sanity. The  defence  objected  to  the  State's  experts  examining 
the  defendant  without  their  presence,  and  finally  they  decided 
that  they  should  examine  him  together.  The  man  was  a  very 
shrewd,  sharp,  sprightly  fellow,  and  they  had  some  difficulty  in 
coming  to  a  conclusion.  The  whole  circumstance  of  the  man's 
heredity  and  professional  history  to  his  implication  in  the  crime 
was  brought  out,  and  finally  led  them  to  agree  that  he  was  not 
fully  responsible  for  the  act,  and  I  think  perhaps  he  was  im 
prisoned  for  life.  This  seems  to  me  to  be  the  solution  of  the 
whole  trouble — that  experts  should  meet  and  come  to  some  con- 
clusion among  themselves.  I  was  summoned  on  a  case  that  way, 
and  I  went  to  my  brother  doctor  and  said  that  I  didn't  want  any 
court  house  scene,  and  if  he  had  a  different  opinion  about  the 
case,  I  wanted  to  know,  and  we  finally  agreed  what  we  would 
testify,  and  had  no  trouble  about  it.  I  do  not  know  what  help 
we  could  get  from  the  law-makers  on  this  line  of  expert  testi- 
mony. 


EXCISION  OF  GALL  BLADDER  FOR  IMPACTED 
GALL  STONE.* 

Bv  W.  Sinclair  Davidson,  M.D.,  Triangle,  N.  C. 


n 


RS.  G.,  age  40  years.     About  the  last  of  August,  1890,   on 

pressure,  she  detected  a  small  tumor  in  the  right  side  and 

sent  for  her  physician,  Dr.  D.  McD.  Yount,  of  Conover, 

Read  at  45th  Annual  Meeting  of  the  North  Carolina  Medical  Society,  Char- 
lotte, May  3,  1898. 


^22  DAVIDSON-INCISION  OF  GALL  BLADDER  ETC. 

N.  C.,  who  also  detected  it.  I  was  asked  to  see  her  December, 
i8go.  Shortly  after  detecting  the  tumor,  the  patient  suffered 
with  a  burning  sensation  in  the  region  of  the  stomach,  and  when 
out  of  recumbent  position  for  a  few  minutes,  intense  nausea  and 
vomiting  ensued.  As  the  tumor  conti-nued  to  increase  in  size, 
the  patient  lost  all  desire  for  nourishment,  and  when  any  was 
taken  nausea  and  vomiting  were  immediately  produced. 

On  February  5,  1891,  I  was  called  to  see  the  patient  again 
and  found  a  very  large  tumor,  the  patient  very  much  emaciated, 
and  suffering  great  pain,  together  with  incessant  vomiting  when 
not  in  a  recumbent  position.  As  the  symptoms  continued  to 
grow  woise,  we  decided  to  operate  that  evening  at  i  o'clock. 
The  abdomen  having  been  well  shaved  and  washed  with  a  solu- 
tion of  bichloride  ot  mercury,  the'  patient  was  placed  upon  a 
table  and  thoroughly  anesthetized  with  chloroform  and  an  incis- 
ion about  seven  or  eight  inches  long  was  then  made  over  the 
tumor,  three  inches  to  the  right  of  the  umbilicus.  On  exposing 
the  tumor  to  view,  I  found  it  to  be  a  distended  gall  bladder, 
filled  with  a  fluid  and  gall  stones,  63  in  number.  Eighteen 
ounces  of  the  fiuid  was  removed  with  an  aspirator.  On  making 
an  examination  of  the  neck  of  the  gall  bladder,  I  found  a  large 
gall  stone  lodged,  that  could  not  be  removed.  After  passing  a 
cat  gut  ligature  through  the  neck  of  the  gall  bladder  above  the 
gall-stone,  it  was  then  tied  and  the  gall-bladder  incised  just  be- 
low the  ligature.  It  was  then  dissected  from  the  liver,  using 
very  hot  water  to  control  the  hemorrhage  from  the  liver.  After 
all  hemorrhage  was  stopped  the  wound  was  closed  with  silk 
sutures  and  dressed  with  bichloride  gauze  and  absorbent  cotton. 
The  sutures  were  removed  nine  days  after  the  operation.  The 
wound  had  united  by  first  intention.  The  patient's  recovery 
was  uninterrupted  with  the  exception  of  an  attack  of  peritonitis, 
which  occurred  a  short  time  after  the  sutures  were  removed.  It 
has  now  been  more  than  seven  years  since  the  gall  bladder  was 
removed,  and  at  this  time  the  patient  is   enjoying  good  health. 


NORTH  CAROLINA  MEDICAL  JOURNAL. 

ROBERT  D.   JEWETT,  M.D.,  Editor 


DEPARTMENT  EDITORS 

H.  T.  Bahnson.  M.D.,  Salem,  N.C. 
SURGERY:     -!      R.  L.  Gibbon, M.D.,  Charlotte,  N.  C. 

J.  Howell  W  ay,  M.D.  ,  Waynesville,  N.  C. 

NERVOUS  DISEASES:— J.  Allison  Hodges,  M,D.,  Richmond,  Va. 
PRACTICE  OF  MEDICINE.  ]    «•  Westry  Battle,  M.D.,  U.  S.  N. 

f\aii^v"vr>r(^ci-       <      GEORGE  G.  THOMAS,  M.D.,  Wilmington,  N.  C. 
UBisii^iitiUb.      -^     p,    L.  Payne,  M.D.,  Norfolk,  Va. 

(      H.  S.  LOTT,  M.D.,  Winston,  N,  C. 
GYNAECOLOGY:     \     J.  W.  Long,  M.D.,  Salisbury,  N.  C. 
(     H.  A.  Royster,  M,D.,  Raleigh,  N.  C. 

PATHOLOGY:— Albert  Anderson,  M.D.,  Wilson,  N.  C. 

PEDIATRICS:— J.  W.  P.  Smithwick,  M.D.,  La  Grange,  N.  C. 

TRANSLATION  AND  FOREIGN  REVIEWS: 

Richard  H.  Whitehead,  M.  D.,  Chapel  Hill,  N.  C. 


All  communications,  either  of  a  literary  or  business  nature,  should  be 
addressed  to,  and  any  remittances  by  P.  O.  Order,  Draft  or  Registered  Let- 
ter, made  payable  to  Robert  D.  Jewett,   M.D.,  Winston,  N.  C. 

jeMtoriaL 


LIQUID  AIR. 


At  a  recent  meeting  of  the  Nevv  York  section  of  the  Society  of 
Chemical  Industry,  Mr.  Charles  E.  Tripler  presented  a  paper  on 
"The  Liquefaction  of  Air  on  a  Commercial  Basis"  (The  Phar- 
maceutical Era)  accompanying  his  paper  by  numerous  experi- 
ments which  went  to  show  the  many  practical  purposes  to  which 
liquid  air  may  be  put.  The  temperature  of  liquid  air  is  about  320° 
below' zero,  and  Mr.  Tripler  brought  upon  the  stage  with  him  a 
large  cask  of  the  liquid  from  which  he  and  his  assistants  scooped 
dipperfuls  for  the  experiments.  This  was  standing  open  like  a 
cask  of  water,  and  some  of  it  placed  in  a  globular  glass  vessel 


EDITORIAL. 
424 

was  beautifully  transparent  and  had  the  appearance  of  water. 
In  an  open  container  the  nitrogen  of  the  air  having  a  lower  boil- 
ing point  than  the  oxygen  slo.vly  evaporates,  leaving  a  residue 
of  pure  liquid  oxygen.  Liquid  air  boils  in  the  atmosphere  at 
312  to  320°  F.  but  is  quiet  in  a  vacuum.  A  dipperful  thrown 
upon  the  floor  made  the  same  splashing  sound  as  would  water, 
a  volume  of  steam  arose,  but  there  was  no  evidence  of  moisture 
upon  the  floor,  so  instantaneous  was  the  evaporation.  There  is 
no  tendency  to  explosion  unless  the  liquid  is  confined  or  unless 
heat  be  applied  in  which  case  its  expansive  force  is  as  great  as 
any  known  explosive.  Among  the  experiments  were  the  follow- 
ing: a  whiskey  cocktail  was  mixed  and  had  the  appearance  of 
snow,  and  was  so  cold  that  it  would  blister  the  tongue  worse 
than  would  the  "chained  lightning"  from  Wilkes;  absolute 
alcohol  was  frozen  and  Mr.  Tripler  stated  that  he  could  freeze 
everything  known  in  nature  except  hydrogen  ;  a  glassful  of  liquid 
air  poured  into  a  carafe  of  water,  floated  upon  the  surface  of 
the  water,  but  occasionally  globules  of  the  air  would  dive  into 
the  water  and  return  again  to  the  surface,  the  globules  diving 
deeper  and  deeper  until  one  reached  the  bottom  of  the  vessel 
when  the  process  ended;  beef,  vegetables  and  fruit  were  frozen 
so  that  they  could  be  pulverized  by  pounding;  tin  by  immersion 
in  the  liquid  air  was  rendered  as  brittle  and  delicate  as  egg 
shell;  mercury  was  frozen  into  the  form  of  a  hammer  and  with 
it  a  nail  was  driven  through  an  inch  board;  a  bar  of  mercury 
was  made  which  supported  a  weight  of  75  pounds  for  15  minutes; 
there  were  also  other  experiments  equally  interesting.  Mr, 
Tripler  did  not  offer  any  suggestions  as  to  the  use  that  cjuld  be 
made  of  liquid  air  in  chemistry,  but  brought  his  lecture  to  a  close 
by  referring  briefly  to  the  history  of  the  manufacture  of  liquid 
air.  ■  The  beginning  of  its  history  might  be  found  in  the  experi- 
ments  with  gases  performed  by  Faraday;  in  1878  Pictet  showed 
that  air  was  not  a  stable  gas  and  could  be  reduced  to  another 
form  in  minute  quantities;  the  matter  was  taken  up  and  studied 
by  the  Royal  Institute,  by  Russian  observers,  and  finally  by 
Linde,   of  Germany. 


IReviewe  an^  'BooJ;^  IRoticee. 

Sexual  Neurasthenia.— Its  Hygiene,  Causes,  Symptoms  and 
Treatment.  With  a  chapter  on  Diet  for  the  Nervous.  By  George  M. 
Beard,  A.  M. ,  M.  D,,  formerly  lecturer  on  Nervous  Diseases  in  the 
University  of  the  city  of  New  York;  etc.,  etc.  Edited  with  Notes  and 
Additions,  by  A.  D.  Rockwell,  A.  M.,  M.  D.,  Formerly  Professor  of 
Electro-Therapeutics  in  the  N.  Y.  Post-graduate  Medical  School  and 
Hospital,  etc.,  etc.  Fifth  Edition  with  Formulas.  Cloth,  octavo,  pp. 
308.     E.  B.  Treat,  New  York,  1898. 

The  rapid  exhaustion  of  the  preceding  editions  of  this  work 
speaks  for  its  popularity.  The  subject  is  one  that  appeals  to 
every  physician,  and  one  on  which  nearly  all  feel  they  need  en- 
lightenment. With  the  various  revisions  the  author  considers 
that  the  work  is  now  practically  complete.  He  has  dwelt  at 
length  upon  the  treatment  of  these  cases,  and  offered  a  set  of 
formulae  which  will  be  found  useful. 

A  Text-Book  on  Surgery.— General,  Operative,  and  Mechanical. 
By  John  A.  Wyeth,  M.  D-,  Professor  of  Surgery  in  and  President  of 
the  Faculty  of  the  New  York  Polyclinic  Medical  School  and  Hospital; 
State  Surgeon  to  Mount  Sinai  Hospital  and  consulting  Surgeon  to  St. 
Elizabeth's  Hospital;  Member  of  the  New  York  Pathological  Society; 
of  the  New  York  Surgical  Society;  etc.,  etc.  Third  edition  is  revised 
and  enlarged.  Royal  octavo,  pp.  997.  Price— cloth  $7.00,  sheep  $8.00; 
by  subscription.     D.  Appleton  and  Company,  New  York.  1898. 

This  is  in  fact  a  revised  edition  of  this  excellent  treatise,  for 
the  advances  in  the  art  of  surgery  have  been  so  marked  since 
seven  years  ago,  when  the  second  edition  was  published,  that 
the  author  has  found  it  necessary  to  practically  re-write  this 
volume.  While  the  features  of  the  original  work,  which  ren- 
dered it  so  useful  to  the  general  practitioner  for  ready  reference, 
are  retained,  the  author  has  added  to  this  edition  some  elemen- 
tary pages  which  will  commend  it  to  teachers  for  tkeir  under- 
graduate pupils. 

The  opening  chapters  are  devoted  to  non-infective  and  infec- 
tive inflammations  and  the  process  of  repair  in  the  tissues ;  specific 
and  non-specific  urethritis;  surgical  diseases,  such  as  erysipelas, 
hospital  gangrene,  glanders,  tetanus,  etc.  After  this  follows  in 
order  chapters  on  minor  surgery,  special  attention  being  given 
to  aseptic  and  antiseptic  technique;  amputations;  surgery  of  the 
lymphatic  vessels  and  arteries;   fractures  and   surgical    diseases 


■  25  NOTES    AND  ITEMS 

of  bones;  dislocations  and  diseases  of  joints.  Chapters  XVIII 
to  XX  are  devoted  to  surgery  of  the  head,  eyes,  nose,  face, 
mouth,  oesophagus  and  trachea.  The  next  four  chapters  study 
diseases  and  surgery  of  the  abdomen;  chapter  XXV.  of  the  rec- 
tum and  anus;  chapters  XXVI  to  XXIX  of  the  genito-urinary 
organs  of  the  male  and  female.  The  volume  ends  with  a  chapter 
on  deformities  and  one  on  tumors. 

Each  department  gives  evidence  of  the  author's  extended  ex- 
perience and  study.  While  the  chapters  on  special  lines  of 
work,  such  as  ophthalmology  and  gynoecology  are  not  as  full  as 
the  specialist  would  desire,  they  give  the  general  practitioner  a 
clear  and  concise  review  of  these  subjects,  and  are  more  com- 
plete than  they  are  usually  found  to  be  in  works  on  general 
surgery. 

The  work  is  fully  illustrated  with  cuts  and  colored  plates 
which  are  excellent,  and  greatly  aid  the  reader  in  a  quick  and 
correct  comprehension  of  the  text. 


IFIotee  an^  Uteme. 


QUESTIONS  SUBMITTED  BY  STATE  BOARD  OF  MEDI- 
CAL EXAMINERS,  AT  CHARLOTTE,  1898. 

Surgery. — Dr.  J.  M.   Baker. 

T.  Define  (a)  septic  infection,  (b)  septic  intoxication,  (c)  ery- 
sipelas, (d)  osteomyelitis  and  (a)  aphasia.  2.  What  are  the 
symptoms  and  treatment  of  fracture  of  neck  of  femur?  3.  Give 
the  symptoms  of  (a)  cerebral  concussion,  (b)  cerebral  compres- 
sion, (c)  shock,  (d)  concealed  hemorrhage,  and  (e)  aneurism.  4. 
What  is  the  pathology  of  (a)  acute  abscess,  (b)  phelebitis,  and 
(c)  lymphadenitis.  5.  What  is  the  treatment  of  (a)  talipes  equi- 
nus,  (b)  chronic  abscess,  (c)  internal  hemorrhoids,  (d)  peritonitis, 
and  (e)  ingrowing  toe  nail,  6.  Give  etiology  of  (a)  inflamma- 
tion, (b)  gangrene,  (c)  anthrax,  (d)  caries,  (e)  synovitis.  7.  Give 
the  diagnosis  of  (b)  conjunctivitis,  (c)  cystitis,  (d)  stricture  of 
urethra  and  (e)  cerebral  embolism.  8.  Discuss  the  clinical  aspect 
of  (a)  appendicitis,  and  (b)  penetrating  wounds  of  abdomen 
with  injury  of  viscera. 


NOTES    AND   ITEMS. 

Chemistry. — Dr.  K.  P.  Battle,  Jr. 

I.  Give  an  example  of  a  chemical  equation  and  explain  its 
meaning.  2.  Give  the  physical  properties  of  Chlorine,  Potas- 
sium, Acetate  of  Lead  and  Sulphate  of  Copper.  3.  Give  the 
chemical  proprieties  of  Nitric  Acid,Hydrogen  Dioxide  (Peroxide) 
and  Hydrogen.  4.  Name  the  substances  having  the  following 
formulae:  H,S,  As  H,,  MgSO,,  NaCl,  CaCo,,  and  give  the  for"^ 
mulae  for  Sulphide  of  Iron,  Iodide  of  Potassium,  Calomel, 
Glucose  and  Chloride  of  Zinc.  5.  Give  some  of  the  peculiari- 
ties which  distinguish  the  organic  compounds  from  the  inorganic. 
6.  What  is  an  Alkaloid?  Name  as  many  of  those  used  in  medicine 
as  you  can.  7.  Describe  two  methods  of  testing  urine  for 
Albumen.  8.  From  a  chemical  point  of  view  what  are  the  fol- 
lowing: Ptomaines,  Caustic  Potash,  Creosote.  9.  How  would 
you  disinfect  the  bowel  discharges  of  Typhoid  Fever? 
Materia  Medica. — Dr.  D.  T.  Tayloe. 

I.  What  are  the  physiological  effects  of  belladonna  and  its 
alkaloids?  Their  dose  and  preparations?  2.  Salicin,  salicylic 
acid  and  the  salicylates— What  are  these  substances,  physiologi- 
cal action  and  medical  uses?  3.  What  are  the  preparations  and 
doses  of  arsenic,  and  what  are  the  medical  uses?  4.  What  are 
the  preparations  of  aconite,  their  dose  and  medical  uses?  5.  Are 
the  mercurial  preparations  ever  used  as  diuretics?  6.  How  do 
the  physiological  actions  of  ether  and  chloroform  compare?  7. 
What  is  the  physiological  action  of  opium,  and  what  are  the 
preparations  and  doses  of  opium  and  its  alkaloids?  8.  What 
are  the  symptoms  and  treatment  of  chloral  poisoning?  9.  Give 
the  differential  diagnosis  between  opium  poisoning,  cerebral 
apoplexy,  alcoholic  intoxication  and  uraemic  coma.  10.  Give 
doses  of  the  following:  Magnesium  sulphate,  potassium  bi  tar- 
trate, oleum  Tiglii  and  elaterium.  11.  What  are  the  medical 
uses  of  ergot? 
Physiology. — Dr.  T.  E.  Anderson. 

I.  Mention  three  properties  of  the  cell,  and  explain  its  func- 
tion in  physical  organization.  2.  Give  structural  difference  be- 
tween arteries,  veins  and  capillaries.  3.  What  digestive  changes 
occur  in  the  large  intestine?  4.  Relate  ist,  The  steps  in  the 
coagulation  of  blood;  2nd,  What  salt  is  necessary  to  its  coagu- 
lation ;  3rd,  Why  does  it  not  coagulate  in  the  living  vessels,     5. 


^28  •     NOTES    AND  ITEMS. 

Name,  locate  and  give  the  function  of  each  of  the  varieties  of 
epithelia.  6.  Name  the  motor  nerve  of  the  tongue.  7.  Give 
the  physiology  of  the  afferent  fibers  of  the  fifth  nerve.  8.  Define 
secretion,  excretion,  and  give  the  function  of  three  secretions,  in 
the  human  economy.  9.  What  is  the  corpus  lufeum^  and  how  is 
it  significant  of  pregnancy?  10.  Explain  the  peristaltic  move- 
ment of  the  bowels,  and  what  effect  does  the  arrest  of  blood 
supply  have  on   it? 

Anatamy. — Dr.  J.  Howell  Way. 

I.  Describe  the  femur.  2  Describe  the  occipital  bone.  3. 
Give  classification  of  joints.  4.  Describe  the  shoulder  joint.  5. 
Describe  the  pectoralis  major  muscle.  6.  Name  and  describe 
the  muscles  of  the  posterior  tibio-fibular  region,  superficial  layer. 
7.  Give  relations  of  external  iliac  artery.  8.  Describe  the  ex- 
ternal carotid  artery  and  name  its  branches.  9.  Name  and  de- 
scribe the  coverings  of  the  brain.  10.  Describe  the  glosso- 
pharyngeal nerve. 
Obstetrics — Gynecology — Pediatrics. — Dr.  H.  B.  Weaver.' 

I.  Describe  the  Uterus,  giving — (1)  arrangements  of  its  mus- 
cular fibers;  (2)  distribution  of  its  blood  vessels  and  nerves;  (3) 
description  of  its  external  and  its  internal  linings. 

II.  How  is  Extra-Uterine  Pregnancy  classified?  (i)  What 
are  its  efifects  on  the  womb?  (2)  What  are  the  symptoms  and 
diagnosis?     (3)  (j'wo.  general  and  specific  treatment. 

III.  What  are  the  causes  of  Post-Partum  Hemorrhages? 
What  are  the  symptoms?  What  is  the  treatment,  and  Jiow  is  it 
to  be  carried  out? 

IV.  Define  Puerperal  Septicaemia:  (1)  Give  its  etiology :  (a) 
Is  it  heterogenetic  or  autogenetic?  (b)  Do  the  retention  and  de  • 
composition  of  the  secundines  produce  the  disease?  (2)  What 
are  the  symptoms  and  course  of  an  attack?  (3)  Give  in  detail 
the  treatment. 

V.  Pelvic  Peritonitis:  (i)  What  is  pathology?  (2)  What  are 
the  varieties?  (3)  Give  its  etiology.  (4)  Describe  the  symp- 
toms.    (5)  What  is  the  treatment? 

VI.  Describe  briefly  the  operation  of  Vaginal   Hysterectomy. 

VII.  (i)  How,  and  from  what  must  you  differentiate  an 
Ovarian  Cyst  in  the  Abdominal  Cavity?  (2)  Describe  the  prin- 
cipal points  in  the  technique  of  a  Laparotomy  for   the   removal 


NOTES  AND  ITEMS. 

429 

of  the  Uterine  Appendages  or  a  Cyst?     (3)   How  would  you  tie 
a  Staffordshire  Knot? 

VIII.  Chronic  Endometritis— (t)  Define  and  give  the  varieties. 
(2)  What  is  the  pathology?  (3)  What  are  the  causes?  (4)  Give 
symptoms  and  physical  signs.      (5)   Give  the  treatment. 

IX.  What  is  Noma?  (i)  What  are  ihe  causes?  (2)  What  are 
the  symptoms?  (3)  What  is  the  prognosis?  (4)  What  is  the 
treatment? 

X.  Define  Entero-Colitis.  (i)  What  are  its  causes?  (2)  De- 
scribe the  anatomical  lesions.  (3)  Give  the  symptoms.  (4)  What 
is  the  treatment? 

Practice  of  Medicine. — Dr.  Taylge. 

I.  What  are  the  pathological  changes  in  chronic  dysentery, 
and  what  are  the  symptoms  of  this  disease?  2.  What  is  acute 
poliomyelitis,  symptoms,  treatment  and  pathology?  3.  Describe 
malarial  cachexia,  and  give  tieatment.  4.  What  are  the  causes 
of  grastric  ulcer,  and  what  are  its  symptoms?  5.  What  are  the 
varieties  of  bronchitis?  6.  What  are  the  physical  signs  of  acute 
pleurisy?  7.  What  is  cardiac  dilatation,  and  what  are  the  causes 
of  this  affection?  8.  How  is  thoracic  aneurism  recognized?  9, 
What  is  acute  parenchymatous  nephritis,  and  what  are  the 
symptoms?     10.    How  should  erysipelas  be  treated? 

Dr.  Russell  Bellamy,  formerly  of  Wilmington,  was  married 
April  2oth,  to  Miss  Constance  Trenholm,  at  St.  Thomas'  Church, 

New    York.      The   bride   is   the   daughter  of Trenholm, 

Comptroller  of  the  Treasury,  under  Mr.  Cleveland's  adminis- 
tration. The  wedding  was  a  conspicious  society  event  in  New 
York. 

Dr.  William  T.  Woodley,  of  Charlotte,  was  married  Apiil 
2ist,  to  Miss  Katharine  Panill,  of  Claremount,  Virginia. 

Dr.  A.  J.  Crowell  removes  from  China  Grove  to  Charlotte. 

Dr.  E.  A.  Cobleigh  has  resumed  his  duties  as  Dean  of  the 
Chattanooga  Medical  College,  after  a  respite  of  a  year  from  of- 
ficial cares  on  account  of  physical  indisposition.  We  are  pleased 
to  note  Dr.  Cobleigh's  restoration  to  health. 

Dr.  D.  McL.  Graham   died   April   28,    1898,    at  his   home   in 


^^O  READING   NOTICES. 

Wallace,  N.  C.  He  was  about  65  years  of  age  and  had  beeen 
in  bad  health  for  several  years.  He  was  a  native  of  Fayette- 
ville.  He  served  as  assistant  surgeon  in  the  37th  N.  C.  Regi- 
ment during  the  civil  war. 

Correction. — By  some  error  the  excellent  and  interesting 
paper  on  "Some  Reflections  on  Post-Graduate  Instruction"  in 
issue  of  May  5th,  was  credited  to  Dr.  C.  E.  Moore.  It  was  pre- 
sented   by   Dr.    E.    G.    Moore. 

To  Guard  Against  Yellow  Fever. — Upon  request  of  the 
Secretary  of  the  Treasury  the  Secretary  of  the  Navy  has  issued 
to  the  commandant  of  the  United  States  Naval  Station  at  Key 
West  and  the  Commander-in-chief  of  the  North  Atlantic  Squad- 
ron instructions  to  keep  a  lookout  for  and  apprehend  any  small 
vessels  whichit  is  believed  intend  to  effect  a  surreptitious 
landing  on   the  Florida  coast. 


IReaMng  "fflotices. 

THYROID  THERAPY  IN  CRETINISM. 


During  the  past  few  years  much  clinical  testimony  has  been 
accumulated  on  the  value  of  thyroid  feeding  in  cretinism,  a  di- 
sease of  children  analagous  to  myxoedema  in  adults.  In  view  of 
the  fact  that  in  cretins  the  thyroid  glands  are  absent  or  imper- 
fectly developed  it  is  easy  to  understand  the  efficiency  of  thyroid 
medication  in  this  disorder.  To  derive  the  best  effects  from 
this  treatment  some  authorities  regard  it  as  preferable  to  employ 
in  place  of  the  fresh  thyroid  gland  or  of  extracts  of  inconstant 
curative  properties,  its  active  principle  iodothyrine.  Experience 
has  shown  that  unpleasant  and  even  alarming  symptoms  are  not 
rarely  observed  during  administration  of  thyroid  extracts,  and 
these  have  been  attributed  to  the  presence  of  toxic  decomposi- 
tion products  in  these  preparations.  On  the  other  hand,  iodo- 
thyrine is  entirely  free  from  by-products,  and  represents  the 
active  constituents  of  the  thyroid  triturated  with  sugar  of  milk 
in  a  definite  and  uniform  proportion,  one  part  being  equivalent 
in  curative  power  to  one  part  of  fresh  gland.  Inasmuch  as  there 
is  no  means  of  determining  the  quantity  of  active  ingredient  in 
any  thyroid  extract,  it  is  difficult  to  so  regulate  its  dosage  as  to 
obtain  the  best  and  safest  effect,  while  this  disadvantage  does 
not  apply  to  iodothyrine,  which  permits  of  accuracy  of  dosage 
and  reliability  of  effect. 


SYR.  HYPOPHOS.  CO.,  FELLOWS 

ion  a  is   the  Esse  tial  Elements  of  the  AninialOrgaiii7.atJon— Pota.sh  and  Urn.-: 

'he  Oxidising  Agents— iron  and  Maganese: 

'he  Tonics Quinine  and  Strychnine; 

ind  the  Vitalizing  Constituent — Phosphorus;  the  whole  combined  in  the  fonii 
of  a  Syrup  with  slightly  All\:aline  Bacteria, 

t  Differs  in  Its  Effects  from  all  Analogous  Preparations;  and  it  posses- 
ses the  important  proj^erties  of  being  pleasant  to  the  taste,  easily  borne  by  th<- 
stomach,  and  harmless  under  prolonged  ase, 

l;haS  Gained  a  Wide  Reputation  particularly    m   the  treatment  of  Pulmonary 
i        Tuberculosis,  Chronic  Bronchitis,  and  other  affections  of  the  respiratory  organs. 

It  has  also  been  employed  with  much  success  in  various  nervous  and  debilitating 

diseases. 

jtS  Curative  Power  is  largely  attributable   to    its  stimulant,  tonic,  and  nutritiv<- 


properties,  by  means  of  which  the  energy  of  the  system  is  recruited. 
lis  Action  is  Prompt;  it  stimulates  the  appetite  and  the  digestion,  it   promotes  as- 

tiimilation.  and  it  enters  directly  into  the  circulation  with  the  food  products. 
he  jirescribed  dose  produces  a  feeling  of  buoyancy,  and  removes  depression  and  mel- 
u;li()[y;  hence  the  preparation  is  of  great  value  in  the  treatment  of  mental  and  nervous 
Teclions.     From  the  fact,  also,  that  it  exerts  a  double  tonic  influence,  and  induces  a 
•alDiy  flow  of  the  secretions,  its  use  is  indicated  in  a  wide  range  of  diseases. 


NOTICE-CAUTION. 

The  success  of  Fellows'  Syrup  of  Hypophosphites  has  tempted  certain 
jrsons  to  offer  imitations  of  it  for  sale.  Mr.  Fellows,  who  has  examined 
omples  of  several  of  these,  finds  that  no  two  of  them  are  identical, 
id  that  all  of  them  differ  from  the  original  in  composition,  in  freedom 
om  acid  reaction,  in  susceptibility  to  the  effects  of  oxygen  when  ex- 
)sed  to  light  or  heat,  in  the  property  of  retaining  the  stry ch- 
ine in  solution,  and  in  the  medicinal  effects. 

A.s  these  cheap  and  inefficient  substitutes  are  frequently  dispensed  in- 
ead  of  the  genuine  preparation,  physicians  are  earnestly  requested, 
hen  prescribing  the  Syrup,  to  write  "Syr.  Hypophos.  Fellows." 

As  a  further  precaution,,  it  is  advisable  that  the  Syrup  should  be 
'dered  in  the  original  bottles ;  the  distinguishing  marks  which  the  bot- 
es (and  the  wrappers  surrounding  them)  bear,  can  then  be  examined, 
id  the  genuineness — or  otherwise — of  the  contents  thereby  proved. 


MEDICAL  LETTERS  MAY  BE  ADDRESSED  TO 


48  Vesey  Street.  New  York. 


Tablet 
Therapy 


liiiiiiiiiiiii 

"^^1    UCTOPEPTINE ; 


-*-  *#««^*|TABLETS|^,^^';i.| 

•t      '-v.f— '  -^5  Grains  each.    ^^^iZ^  ■  .>  j 

k  \  lactopfpifpf  conlainsall  known  Substahces-  *  ] 

T  employed  by  Nalurf  in  IhcDigfSiwn  dial!  >*/ 

i1^  kinds  of  Food.  ^-' 

V,  Supfriorloallo(herRe)nf<h"esr<)rDys-^i 

r*  pcpsialndisJfslionandkmdreddil-  ^. 

^V  menis  ducloDi^esiiveDcIjibt/    ^-^ 

V    DoSL2  10  4  TAB1.LTS <f TfH  MCKHHU  ^*  j' 

' ,  *  THE  KwroM  ^mmw.  *ssocuiiO»->' , 


Undoubtedly  stands 
high  in  the  professional 
estimation  at  the  pres- 
ent time^  and  justly  so 
on  account  of  the  many 
clinical  a  d  v  a  n  t  a  g  e  s 
which  it  possesses  as  a 
method  of  medieation^  Wenow  manuracttife  Lactopeptlne 
in  tablet  form  (fi-^e  grains- each)  and  to  still  further  increase 
their  therapeutic  efficiency,  We  have  added  a  small  quantity 
of  bromelin,  the  vegetable  digestive  ferment  recently 
isolated  from  pineapple  juice.  The  Lactopeptine  Tablet 
renders  it  easier  for  business  men,  or  those  who  are  away 
from  home  during  the  day,  to  carry  the  remedy  with  them 
in  a  convenient  form  for  administratiott  at  regular  intervals 
as  described  by  the  physician. 


PlefasC  note  especially  that  each  tablet  is  plainly 
stamped  with  the  initials  N.  Y,  P.  A.  to  prevent  sub- 
stitution. 

Put  up  in  bottles  containing 

100  5-Kr.  Tablets  and  50  5-gr.  tablets. 


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©ricjinal  Communications. 


EXTRA  UTERINE  PREGNANCY.* 
By  MoRDECAi  Prick,  M.  D.,  Philadelphia,  Pa. 


[APPRECIATE  the  courtesy  of  your  invitation  to  participate 
in  your  proceedings,  and  I  further  appreciate  the  respnsi- 
bility  which  attaches  to  addressing  young  men  about  to 
cross  the  threshold  into  the  active  duties  of  one  of  the  most  im- 
portant, responsible  and  di*ficult  of  professions.  There  should 
be  no  uncertainty,  nothing  equivocal  in  the  voice  that  would  give 
wise  and  safe  counsel;  the  lessons  conveyed  should  be  those  of 
clinical  or  bedside  experience. 

However  well  taught,  however  carefully  and  judiciously  you 
may  cull  and  treasure  up  the  lessons  of  text  book  and  lecture, 
and  those  of  youi  experiences  as  you  go  along,  you  will  ever  be 
having  very  much  to  unlearn.  The  literature  of  Extra  Uterine 
Pregnancy  is  abundant,  very  much  of  it  is  theoretical,  speculative, 
merely  huddled  conjectures.  There  are  associated  with  the  ac- 
cident disputed  problems. 

Our  advances  in  abdominal  surgery  and  the  revelations  of  the 
post-mortem  have  cleared  away  some  of  the  pi  thological  difficul- 
ties— as  to  others  we  yet  only  theorize,  must  work  and  wait  for 
better  light.    For  the  sake  of  the  truth  we  should  not  dogmatize. 

Along  all  lines,   medical  and  surgical,  our  views  are  modified 

by  our  experiences.      However  positive  may  be  our  views  along 

any  given  line  it  is  certainly  well  to  take  into  consideration  the 

*Read  before  the  John  BTOeavor  Medical  Society  of  the  University  of  Penn- 
sylvania, April  15,  1898. 


^,2  PRICE-EXTRA  UTERINE  PREGNAXCY. 

possibility  of  being  mistaken.  There  is  good  counsel  in  a  letter 
of  Oliver  Cromwell  to  the  General  Assembly  of  the  Kirk  of 
Scotland  *'I  besceecb  you  brethren,  by  the  mercies  of  God,  con- 
ceive that  you  may  be  mistaken." 

As  a  rule  these  cases  first  come  under  the  obse-vation  of  the 
general  physician  and  obstetrician  and  not  that  of  the  abdominal 
surgeon.  To  the  general  practitioner  falls  the  task  of  making 
the  first  diagnosis.  He  should  recognize  that  the  condition  is  a 
perilous  one,  always- urgent.  Doubtless,  even  with  the  light  of 
our  present  experiences,  very  many  of  these  cases  are  not  diag- 
nosed and  not  treated  surgically,  the  only  way  in  which  they  can 
be  treated  successfully;  they  are  left  to  die  and  manv  do  die. 

The  condition  is  too  frequently  unrecognized  or  is  called 
something  else  and  the  patient  is  permitted  to  perish  after  a  little 
opium  or  paliative   treatment.  Some  unquestionably  do  recover. 

We  must  first  diagnose  pregnancy,  and  then  whether  the  con- 
dition is  normal  or  whether  there  is  reasonable  evidence  or  not 
of  extra  uterine  pregnancy. 

The  abdominal  surgeon  rarely  sees  the  patient  before  rupture 
takes  ptace.  Abdonninal  sensations,  severe  pelvic  pain  and 
hemorrhage  from  the  uterus  may  not  alarm  the  patient,  and  in 
many  instances  before  the  primary  rupture  occurs  there  is  not 
even  a  suspicion  of  pregnancy.  It  is  when  rupture  takes  place 
that  the  patient,  family  and  family  physician  recognize  the  peril 
of  the  situation. 

In  all  these  cases  the  mother's  life  is  the  one  consideration;  it 
should  not  be  jeapordized  for  the  sake  of  the  foetus. 

I  cannot  better  define  this  condition  than  that  it  is  an  im- 
pregnated ovum  gone  wrong.  The  question  as  to  how  it  occurs 
and  why  is  a  disputed  one.  It  is  evidently  caused  by  some 
disease  or  abnormal  condition  of  the  tube.  It  is  the  teaching  of 
the  best  authorities  on  the  subject  that  from  some  disease  of  the 
tube  the  impregnation  takes  place  in  the  tube  instead  of  the  womb 
and  as  soon  as  impregnation  takes  place  the  ovum  fastens  on 
tissue  necessary  to  preserve  its  life. 

Mr.  Tait  advances  the  idea  that  extra  uterine  pregnancy  is 
caused  by  whatever  removed  the  ciliated  epithelium  from  the 
Fallopian  tubes.  It  has  been  claimed  by  numerous  operators  that 
it  may  adhere  and  develop  anywhere  in  the  abdomen,  but  from 


PRICE-EXTRA  UTERINE  PREGNANCY 

433 
ray  own  experience  I  can  say  that  I  have  never  seen  another 
than  the  tubal  cases,— those  beginning  in  the  tube. 

It  is  reasoned  by  some  that  the  ordinary  signs  of  pregnancy 
being  present  in  addition  to  the  pelvic  distress  and  pain  on  one 
side  should  warn  us  that  the  pregnancy  may  be  displaced.  If 
with  such  symptoms  there  is  a  bloody  discharge  it  indicates 
either  an  abortion  or  a  ruptured  tubal  pregnancy.  I  believe  that 
as  soon  as  the  rupture  takes  place  the  symptoms  of  hemorrhage 
follow,  and  all  such  cases  should  be  most  carefully  examined  for 
an  extra  uterine  pregnancy.  In  my  experience  the  hemorrhage 
does  not  occur  before  rupture. 

In  discussing  the  subject  Mr.  Tait  says:  "A  tubal  pregnancy 
is  bound  to  rupture  in  the  free  part  of  the  tube;  it  rarely  delays 
beyond  the  twelfth  week  and  may  be  as  early  as  the  fourth;  in 
the  interstitial  part  of  the  tube  from  the  third  to  the  twentieth 
week.  This  rupture  takes  two  directions:  into  the  peritoneum 
which  is  the  fatal  form,  and  into  the  cavity  of  the  broad  ligament. 
The  latter  or  extra  peritoneal,  alone  gives  all  the  cases  which  go 
on  to  the  period  of  viability,  all  the  lithop^dia,  all  the  suppurat- 
ing cysts  discharging  into  the  bladder,  rectum,  vagina,  and 
abdomen,  and  also  all  cases,  which  by  secondary  rupture  of  the 
broad  ligament  into  the  peritoneal  cavity,  are  called  "Abdominal 
Pregnancy." 

I  quote  from  Mr.  Tait  because  I  have  great  respect  for  his 
teaching;  in  about  all  we  do  in  abdominal  surgery  we  all  follow 
his  teaching,  very  many  without  the  credit  due  him;  but  as  to 
the  opinion  I  quote  as  credited  to  Mr.  Tait,  I  must  differ.  My 
own  experience  in  extra  uterine  pregnancy  has  led  me  to  adopt 
an  entirely  different  view  from  that  expressed  by  Mr.  Tait.  I 
believe  that  instead  of  rupture  into  the  broad  ligament  in  nine 
hundred  and  ninety-nine  out  of  a  thousand  cases  the  primary 
rupture  is  into  the  peritoneal  cavity;  and  where  the  case  goes  to 
term,  or  the  life  of  the  child  is  prolonged  beyond  the  period  of 
rupture,  the  tube  has  ruptured  only,  and  the  product  of  concep- 
tion has  been  forced  through  the  rent  in  the  tube  encapsuled  in 
its  amniotic  sac.  No  child  in  the  early  days  of  foetal  life  would 
be  protected  from  the  digestive  influences  of  the  peritoneum. 

The  only  way  an  extra  uterine  pregnancy  can  go  to  term  is 
encapsuled  in   the  amniotic  sac.      The  sac  is  a  foreign  body  in 


.^.  PRICE— EXTRA  UTERINE  PREGNANCY. 

the  peritoneum  and  adheres  to  everything  coming  in  contact 
with  it.  The  adherent  viscera  protect  as  well  as  nourish  the 
displaced  ovum.  In  my  experience  with  those  which  have  gone 
to  term,  or  passed  the  second  month,  the  amniotic  sac  could  be 
demonstrated  in  every  one  of  them.  In  over  two  hundred  cases 
of  extra  uterine  pregnancy  one  hundred  and  sixty  four  in  the 
practice  of  my  brother,  Dr.  Joseph  Price,  and  sixty  odd  in  my 
own,  I  have  neverseen  a  case  develop  in  the  broad  ligament.  The 
peritoneum  would  digest  a  foetus  at  any  age  if  not  protected  in 
some  way  from  its  influence.  The  cases  reported  that  seem  to 
prove  that  a  child  can  live  in  the  peritoneal  cavity  were  not 
carefully  examined. 

The  case  of  Jessop,  of  Leeds,  is  in  point.  In  this  case  there 
is  nothing  to  show  that  the  child  was  not  encapsuled  in  an  amni- 
otic sac  up  to  a  short  time  before  the  operation.  Nature  has 
definite  methods  for  doing  her  work.  She  protects  the  foetus  in 
utero  with  an  amniotic  sac.  There  are  all  the  conditions  present 
in  a  displaced  ovum  for  the  protection  and  growth  of  the  foetus, 
so  far  as  the  product  of  conception  is  concerned.  If  a  child  can 
grow  in  the  tube  or  in  the  peritoneum  nature  must  provide  the 
necessary  paraphernalia. 

If  an  amniotic  sac  exists  in  some  it  exists  in  all.  It  lias  been 
clearly  demonstrated  to  exist  in  all  the  cases  I  have  seen. 

The  possibility  of  the  viability  of  a  child  depends  not  only 
upon  the  protection  of  the  foetus  by  the  amniotic  sac  but  also 
upon  the  life  of  the  placenta.  If  in  the  rupture  the  placenta  has 
been  entirely  detached  death  to  the  foetus  is  certain  to  follow, 
but  if  it  retains  sufficient  hold  to  preserve  its  own  life  and  that 
of  the  child  it  will  soon  form  new  attachments  to  surrounding 
viscera  and  womb  and  the  abdominal  wall  to  insure  the  life  and 
growth  of  the  foetus. 

The  symptoms  are  usually  a  period  of  sterility,  a  missed 
period,  distressing  pelvic  pains,  continuous  bleeding,  a  soft 
velvety  feel  of  the  cervix  as  in  pregnancy,  straining  at  stool  with 
no  result,  feeble  pulse,  intense  palor,  sick  stomach  with  a  boggy 
soft  mass  in  the  pelvis,  on  one  side  or  both,  usually  on  one  side, 
faintness  and  collapse.  With  such  symptoms  we  can  feel  safely 
sure  that  extra  uterine  pregnancy  exists  with  rupture. 

The  mortality  in  these  cases  should  not  be  high,  less  than 
five  per  cent. 


PRICE-EXTRA  CJTERmE  PREGNANCY. 

435 

In  the  early  months  of  tubal  pregnancy  it  is  rare  to  find  a  well 
marked  abdominal  tumor.  After  the  third  month  there  is  a  well 
defined  tumor.  The  blood  becomes  encapsuled  by  irritation  of 
the  peritoneum  and  adherent  viscera,  an  inflammatory  barrier 
thrown  out  to  protect  the  general  peritoneal  cavity.  If  the  case 
has  been  neglecied  this  may  undergo  septic  changes  and  form 
an  abscess  which  may  be  followed  by  sepsis  and  death  of  the 
patient. 

The  cases  that  go  to  term  are  those  not  recognized.  The 
question  is  how  must  we  treat  extra  uterine  pregnancy  in  its 
different  stages?  It  is  a  ruie  to  remove  everything  and  do  it  at 
the  earliest  possible  moment  after  the  occurrence  of  the  accident. 
In  the  early  months,  to  the  trained  abdominal  surgeon,  there  is 
no  operation  easier,  none  that  affords  more  gratifying  results. 

As  the  period  of  the  pregnancy  advances  the  surgical  ques- 
tions and  dangers  increase,  until  the  period  of  viacility  is  reached 
when  the  danger  to  both  mother  and  child  is  very  great  indeed. 
Medical  history  gives  only  eight  or  nine  recoveries  of  both 
mother  and  child.  No  woman  should  be  allowed  such  desperate 
risks  for  so  small  a  chance  of  a  living  child.  The  operation  in 
the  early  months  requires  only  a  few  moments  to  ligate  and  re- 
move the  diseased  tube,  placenta  and  sac,  thoroughly  irrigate 
the  peritoneum  with  warm  water,  temperature  105°  F.  and  use 
glass  drainage. 

As  the  months  go  on  the  magnitude  of  the  operation  increases, 
the  placenta  and  sac  have  formed  adhesions  which  are  hard  to 
break  and  are  usually  followed  by  profuse  hemorrhage.  Up  to 
the  sixth  month  we  have  always  been  able  to  remove  both  pla- 
centa and  sac  entire,  but  have  not  always  been  able  to  stop  the 
profuse  bleeding  by  ligature  alone;  gauze  pack  in  some  of  them 
has  been  necessary  and  it  answers  the  purpose  admirably  ;  though 
it  complicates  and  delays  the  after  treatment,  necessity  justifies 
its.use.  From  the  seventh  month  on,  with  a  living  child  the 
question  in  the  opveration  is  how  to  deal  with  the  placenta.  Re- 
move it  if  possible.  It  is  not  often  possible.  If  not,  then  cut 
short  the  cord,  clean  the  face  of  the  placenta,  clean  perfectly  the 
peritoneal  cavity,  dry  the  parts  and  close  the  abdomen,  and 
trust  to  future  developments  for  the  removal  of  the  placenta  if 
required;   it   may   become    encapsuled    or  absorbed.      Another 


^^5  McGINNIS-SOME  THOUGHTS  ABOUT  TYPHOID  FEVER. 

method  is  to  leave  the  abdomen  open  and  pack  daily  with  gauze 
over  the  face  of  the  placenta  and  wait  for  the  placenta  to  loosen 
and  come  away.  My  case  of  extra  uterine  pregnancy  in  the 
tenth  month  with  living  mother  and  child  was  treated  in  this 
way. 

You  can  judge  this  woman's  danger  when  I  tell  you  that  her 
temperature  ranged  from  95  to  105  for  32  consecutive  days,  when 
she  fell  into  spurious  labor,  part  of  the  placenta  protuded  from 
the  opening,  the  abdominal  muscles  over  the  placenta  contracted 
very  much  as  the  womb  contracted  to  force  the  placenta  from 
its  fastenings.  I  removed  the  placenta  which  was  as  large  as 
my  hat  rim.  The  removal  was  followed  by  a  frightful  hemor- 
rhage which  was  checked  by  packing  the  cavity  with  cheese 
cloth.  From  that  time  she  made  a  rapid  recovery.  Now  five 
years  and  four  months  after  the  delivery  both  mother  and  child 
are  in  perfect  health. 

The  mterstitial  variety,  or  those  cases  partially  covered  with 
uterine  tissue  and  tube,  are  the  most  dangerous  variety,  many  of 
them  perishing  of  hemorrhage  before  assistance  can  be  procured. 
Every  hour  of  delay  in  this  condition  is  fraught  with  danger.  It 
demands  prompt,  courageous  and  skillful  operative  treatment 
to  save  life. 

There  is  no  question  but  that  this  condition  should  be  recog- 
nized before  rupture  takes  place,  but  it  is  rarely  done  for  the 
reason  that  the  woman  rarely  suspects  anything  wrong  so  early 
in  her  pregnancy,  and  does  not  consult  a  physician  until  after 
rupture  takes  place. 


SOME  THOUGHTS  ABOUT  TYPHOID  FEVER.* 
By  R.  H.  McGinnis,  M.  D.,  Charlotte,  N.  C. 


BEING  an   Embryo,    so  to  speak,  in  the  medical  profession 
and  my  first  appearance  before  your  Honorable  Body,  it 
becomes  me  to  say  that  my  paper  will,   no  doubt,  be  ac- 
cepted with  more  or  less  hesitancy. 

I  will  not  attempt,  in  the  time  allotted  me,  to  cover  the  whole 
*Read  at  the  Annual  Meeting  of  the  North  Carolina  Medical  Society,  Char- 
lotte, May  3,  1898. 


McGINNIS— SOME  THOUGHTS  ABOUT  TYPHOID  FEVER. 

literature  embraced  in  the  therapy  of  cold  water,  neither  will  I 
burden  you  with  a  rehearsal  of  all  that  has  been  written  on 
hydrotherapy  in  the  management  of  typhoid  fever,  but  will  en- 
deavor to  place  before  you  some  simple  thoughts  and  sugges- 
tions with  the  report  of  two  cases  which  came  under  my  direct 
observation  in  the  Maryland  University  Hospital  during  the  past 
year.  The  first  case  showing  some  of  the  many  pathological 
conditions  produced  by  the  fever  germ,  the  ocher  the  advantages 
offered  by  hydrotherapy  in  the  management  of  a  much  compli- 
cated case. 

Since  the  introduction  ot  the  antitoxine  treatment  of  diphtheria 
by  Behring,  of  Germany,  and  its  wide  spread  acceptance  by  the 
profession  in  recent  years,  with  such  remarkable  results,  reduc- 
ing the  mortality  from  this  most  fatal  of  the  diseases  of  children 
from  50  to  60  per  cent  to  less  than  20  per  cent,  the  minds  of  the 
pathologists  and  bactheriologists  have,  and  most  naturally, 
turned  to  the  investigation  and  experimentation,  following  simi- 
lar lines  as  did  Behring,  Koch,  Pastenrand  others,  to  elucidate 
a  serum  which  would  be  antagonistic  to  those  tosines  liberated 
in  the  system  by  the  growth  and  development  of  the  typhoid 
bacillus. 

At  the  present  time  little  or  nothing  is  being  published  by 
those  making  such  investigations,  and  the  general  profession  as 
well  as  bacteriologists  are  largely  and  anxiously  expecting  such 
a  discovery  and  we  can  not  but  think  that  the  dawn  of  the  20th 
century  will  disclose  this  great  agent. 

Several  investigators  have  employed  an  anti-typhoid  serum  in 
the  treatment  of  typhoid  fever,  and  their  report  of  something 
over  100  cases  has  appeared  and  not  with  such  discouraging  re- 
sults, most  notably  among  them  being  Fraeknel,  Mauchet, 
Rumpf,  Kraus,  Busvvell  and  Pfeiffer. 

The  first  four  observers  report  nearly  100  cases  and  their  con- 
clusions were  that  the  course  of  the  fever  was  slightly  influenced, 
pyrexia  occurs  in  a  shorter  time,  with  a  general  improvement 
of  the  feelings  of  the  patient  and  disappearance  of  delirium. 
The  last  two  observers  noted  no  specific  action,  reporting  a 
smaller  number  of  cases. 

When  such  an  anti  typhoid  serum  has  been  isolated  and  its 
employment  embraces  a  large  part  of  the  profession  I  can  not 


^^g  McGIIsTNIS-SOME  THOUGHTS  ABOUT  TYPHOID  FEVER. 

believe  th'it  the  mortality  from  this  dreaded,  disease  will  be 
materially  lower  than  by  the  use  of  cold  water,  when  judiciously 
employed,  which  is  less  than  5  percent  in  hospitals  and  in  private 
practice  very  much  less  than  this.  Although  hospitals  as  a 
general  rule  receive  their  patients  in  the  2nd  and  3rd  week  of 
the  disease,  the  mortality  in  the  Maryland  University  Hospital 
for  1896  was  only  2  per  cent  and  for  i^gj  was  only  3  per 
cent,  about  100  cases  being  treated  each  year.  During  the  faU 
and  winter  of  1896  and  '97  fifty  consecutive  cases  of  typhoid 
fever  were  treated  in  the  University  Hospital  and  not  a  single 
death.      All  receiving  the  cold  bath. 

I  would  not  lead  you  to  think  that  I  believe  every  case  of 
typhoid  fever  required  the  cold  bath.  There  are  many  cases, 
and  especially  if  not  treated  before  the  2nd  and  3rd  weeks, 
where  the  cold  bath  would  be  absulutely  harmful,  but  these  are 
the  cases  where  the  cold  sponging  and  cold  pack  plays  such  an 
important  role.  On  the  other  hand  I  have  seen  cases  where  the 
sponging  v.ould  invariably  produce  collapse,  with  extreme 
cyanosis  and  feeble  pulse  and  when  put  into  a  cold  bath,  begin- 
ning at  80°  and  gradually  lowering  it  to  65°  F.,  would  almost 
immediately  show  signs  of  improvement.  During  the  2nd  and 
3rd  weeks  of  disease  the  cold  bath  must  be  employed  with  the 
utmost  care  and  diligence,  every  symptom  carefully  noted  and 
if  the  patient's  condition  will  not  permit  ot  this  measure,  the 
cold  pack  or  sponging  may  be  substituted,  but  if  the  bath  be 
employed  from  the  beginning  there  is  little  need  for  any  sub- 
stitute during  the  3rd  week,  as  I  have  noted  during  my  residence 
at  the  hospital,  having  observed  about  150  or  200  cases.  When  the 
bath  is  judiciously  employed  it  greatly  adds  to  the  general  com- 
fort of  the  patient,  not  only  by  reducing  his  temperature  but  by 
accelerating  the  circulation,  which  is  much  below  normal,  arterial 
tension  being  extremely  low,  due  to  the  hebetude  and  listless- 
ness  of  the  patient ;  stimulating  reflexly  through  the  skin  and  un- 
derlying tissues  all  the  reflexes,  especially  those  of  respiration  and 
of  the  heart,  bringing  about  an  equilibrium  in  the  heat  produc- 
ing and  heat  radaiting  centers,  as  is  shown  by  the  natural  sleep 
the  patient  often  falls  into  after  the  bath;  lessening  of  de- 
lirium and  producing  a  gentle  perspiration.  By  contracting  the 
arterioles  of  the  surface  of  the  body  more  blood  circulates  through 


MCGINNIS-SOME  THOUGHTS  ABOUT  TYPHOID  FEVER 

439 
the  liver,  that  great  barrier  to  autoinfection,  stimulating  it  to 
greater  activity,  thereby  eliminating  from  the  blood  much  of 
the  toxines  of  the  typhoid  germ.  This  action  I  believe  to  be  ?m 
auto-serum  action  where  the  patient  himself  is  made  to  produce 
a  serum  in  his  own  tissues  antagonistic  to  the  infection. 

It  was  found  by  Widal,  Pfeiffer  and  others  in  their  search  of 
the  action  of  the  blood  on  various  bacteria  that  blood  from  a 
typhoid  fever  patient  would  cause  the  immobility  and  clumping 
together  of  the  active  typhoid  bacilli  showing  that  the  patient 
produced  in  his  own  tissues  a  substance  antagonistic  to  the 
toxine  produced  by  the  germ. 

This  reaction  met  with  merited  favor,  and  in  this  country 
was  clearly  demonstrated,  a  diagnostic  feature  of  the  disease, 
by  Johnstone  before  the  American  Congress  of  Physicians  held 
in  Buffalo,  N.  Y.,  in  1897  and  later  the  same  year  at  Philadel- 
phia. He  ordered  blood  sent  him  from  patients  suffering  with 
various  diseases  and  in  every  case  of  typhoid  fever  this  agglutina- 
tion reaction  occurred. 

A  drop  of  blood  is  taken  on  a  cover  glass,  under  aseptic  pre- 
cautions, and  diluted  10,  20  or  30  times,  it  is  then  turned  over 
on  a  glass  slide  with  a  small  excavation,  into  which  the  bacilli 
from  a  fresh  culture  about  36  hours  old  preferably,  has  been 
placed.  By  the  use  of  the  oil  imaiersion  lens,  and  better  by 
artificial  light,  the  germs  are  seen  at  fi'-st  floating  in  the  fluid 
and  very  active,  then  gradually  become  less  and  less  active  until 
finally  they  clump  together  in  various  size  clumps  and  com- 
pletely immobile.  It  generally  requires  from  i  to  2^  or  3  hours 
for  a  complete  agglutination. 

In  many  cases  during  the  last  few  years  where  the  diagnosis 
of  typhoid  had  been  confined  to  this  reaction,  post  mortem 
examinations  have  shown  various  and  extremely  interesting 
lesions,  some  cases  in  which  no  evidence  of  the  disease  existed 
in  the  alimentory  canal.  While  pure  cultures  from  various  other 
organs  affected  showed  only  the  typhoid  bacilli,  no  organ  or  tissue 
of  the  body  is  exempt  from  its  invasion.  Several  cases  of  fatal 
meninigets,  empyema,  and  pericarditis  have  been  reported,  and 
two  cases  where  the  bacilli  were  formed  only  in  the  gall  bladder, 
and  many  cases  of  pneumonia,  one  occurring  in  the  Maryland 
University  Hospital  this  past  winter  which  I  will  briefly  call  to 
your  attention. 


McGINNIS— SOME  THOUGHTS  ABOUT  TYPHOID  FEVEK. 
440 

N.  A.  White,  male,  age  24,  sailor,  Greek  by  birtb.  E-n  erecS 
Ihe  hospital  February  zznd  189S,  in  very  etoaciated  feeble  coa- 
dition.  Speaking  modern  Greek,,  no  previous  history  could  be 
obtained.  Temperature  foi|.,  pu'se  9.6,  repirations  24  at  time 
of  admission  a»d  eold  clammy  Gorrdi-tiou  of  body.  Stimulating; 
him  freely  I  made  an  examirtatron  after  two  or  three  ho urs^  find- 
ing a  pneumonia  o(  lower  right  lobe,,  tympanitic  and  very  tender 
abdomen.  His  pulse  and  respiration  gradually  increased  and  he 
died  72  hours  after  admittance. 

Post  mortem:  exan>ination  revealed  a  perforation  of  small  in- 
testine at  site  of  Peyer's  patches  about  1 8- inches  above  the  caecum, 
and  a  general  suppurative  peritonitis.  Culture  taken  from- 
peritoneal  cavity  and  pneumonic  lung  revealed  the  typhoid 
bacillus.  His  pneumonia  preceded  the  perforation  of  the  intes- 
tine,  showing  that  it  was  not  produced  by  extension  from  the 
peritoneum-.  Such  a  case  is  beyond  the  aid  of  the  physician,  but 
in  those  eases  where  no  intestinal  leasrons  exist  and  the  disease- 
is  limited  to  the  other  organs  it  is  not  very  obvious  that  internal 
administration  of  drugs,  save  those  for  stimulation  and  nutrition,, 
will  not  benefit  the  patient,  but  on  the  other  hand  be  very 
detrimental,  especially  those  that  cause  frequent  movement  of 
the  bowels.  The  disease  is  evidently  one  of  general  infection 
and  not  one  of  intestinal  origin  alone. 

The  other  case  I  wish  to  report  is  that  of  a  married  woman,, 
aged  20,  the  mother  of  two  living  children,  German  by  birth,, 
understanding  very  little  English.  Previous  history  negative,, 
was  taken  with  a  severe  chill  on  July  29tb,  no  treatment  until 
brought  to  hospital  at  9  a.  m.  August  4th,  7  d  lys  after  chilly 
with  temperature  of  105I,  pulse  132,  respiration  52.  Diagnosis 
of  typhoid  fever  made  and  stimulants  ordered,  consisting  of 
strychnia  gr.  ^^  every  4  hours,  whiskey  3  ss  every  2  hours.  At 
9  o'clock  a.  m.,  next  day  temperautre  104I,  pulse  144,  respira- 
tion 49.  Tub  bath  given  and  ordered  continued  when  tempera- 
ture reached  103I  or  over,  temperature  being  taken  every  3 
hours.  Widal  reaction  confirmed  diagnosis.  A  copy  of  her 
chart  I  have  appended  will  show  that  she  received  in  all  34  baths 
covering  a  period  of  8  days.  For  5  days  she  received  a  bath 
every  3  hours  with  four  exceptions,  two  at  6  a.  m.  and  two  on 
the  night  of  the  6th  day,  when  she  was  delivered  of  a  5  months 


McGINNIS-SOiVDi:  THOUGiri'S  ABOUT  TYPHOID  PEVER 

-child  at  midnight.  Patient  began  to  improve  from  very  first 
bath  and  although  delirious  upon  entrance  it  all  disappeared 
after  the  2nd  bath.  No  tympanites  after  2nd  night.  Constipa- 
tion prevailed  throughout  the  entire  period  of  disease,  mostly  re- 
lieved by  enemas.  Milk  diet  and  the  strychnine  and  whiskey 
were  all  that  were  given  internally.  Temperature  assumed  its 
normal  on  the  nth  day  after  admittance  and  remained  withis 
aiormal  limits  until  discharged  from  hospital, 

DISCUSSION, 

Dr.  Taylor: — I  wish  it  were  in  my  power  to  tell  this  Society 
something  it  does  not  already  know  about  the  surgery  of  typhoid 
fever.  It  is  a  comparatively  new  fields  and  you  will  probably 
hear  a  gr. od  deal  more  about  it.  In  my  limited  expe.ience  I 
•have  had  three  cases  which  have  been  sufficiently  impressive  to 
teach  me  that  there  is  a  possibility  of  accomplishing  good  if  the 
■opportutiity  is  taken  at  the  right  time.  The  first  case  that  came 
under  my  observation  was  that  of  a  young  man  who  had  had  a 
mild  attack  of  typhoid  fever,  and  was  practically  convalescent. 
He  probably  then  had  no  fever.  I  was  sent  for  early  one  morn- 
ing and  was  informed  that  that  night  he  had  had  a  chill,  with 
violent  pains  in  the  abdomen.  I  recognized,  not  only  from  the  in- 
creased  temperature,  but  from  the  rapid  pulse  and  the  evidence 
ot  shock  and  the  invasion  of  the  peritoneal  cavity  that  perfora 
tion  had  occurred.  Prior  to  that  time,  this  had  been  a  mild  case 
of  typhoid  fever,  no  hemorrhage  and  no  evidence  of  ulceration. 
I  telegraphed  to  his  brother,  who  is  a  doctor,  that  this  m.an  had 
perforation,  that  the  only  hope  of  saving  him  was  an  immediate 
laparotomy,  and  asked  his  consent  and  his  presence.  He  tele- 
graphed back  that  if  he  had  perforation,  he  was  bound  to  die, 
and  he  didn't  want  to  see  him  die.  His  friends  opposed  the 
operation  and  continued  to  oppose  it  for  probably  three  days. 
At  that  time  his  distend. d  abdomen,  depressed  condition,  with 
all  the  evidences  of  septic  peritonitis,  made  me  fear  with  his 
friends  that  the  end  was  very  near.  Then  they  importuned  lor 
operative  interference.  I  probably  should  not  have  consented, 
because  to  operate  upon  a  case  in  the  last  stage,  perhaps  would 
deter  some  others  from  having  an  operation  performed,  but  it 
might  give  him  a  better  chance  for  life.  And  this  one  instancy 
did  deter  a  subsequent  patient  from  being  operated  upon.  I 
did  operate,  and  opened  the  abdomen.  In  spite  of  the  prolonged 
time,  I  found  that  about  one  half  of  the  abdomen  contained  an 
enormous  abscess  wich  fecal  matter  andpurulent  secretions.  The 
intestines  had  become  massed  and  matted  together,  and  in  spite 
of  the  terrific  invasion,  nature  had  built  its  barrier  around  the 


442 


McGINNIS-SOJVIE  THOUGHTS  ABOUT  TYPHOID  FEVER. 


invading  foe  and  prevented  a  general  peritonitis.  Tiie  patient 
died.  The  next  patient  I  saw  lived  next  door  to  this  j'oung 
man.  Curiously  enough,  she  dreamed  that  she  had  perforation, 
and  that  the  doctors  wanted  to  operate  upon  her,  several  days 
before  it  occurred.  She  implored  her  husband  not  to  let  the 
doctors  operate,  and  she  afterwards  developed  symptoms  of 
perforation.  I  told  her  husband  that  she  had  perforation,  and 
I  think  told  her.  She  did  not  want  to  have  the  operation  per- 
formed, and  her  husband  promised  her  she  should  not  be  oper- 
ated upon,  and  he  would  not  allow  the  operation.  In  48  hours, 
as  I  expected,  she  developed  septic  peritonitis  and  died.  The 
third  case  was  allowed  to  go  on  from  bad  to  worse  for  3  or  4 
days  before  operative  interference  was  sought,  and  in  that  case 
I  found  suppurative  septic  peritonitis.  There  was  a  sl'ght  per- 
foration in  the  ileum,  not  larger  than  a  ten-cent  piece.  Two  or 
three  sutures  if  applied  to  the  center  of  the  perforation,  or  as 
soon  as  the  diagnosis  should  have  been  made,  would  probably 
have  saved  the  patient's  life.  This  little  experience  of  mine  is 
worth  very  little  unless  simply  as  an  introduction  to  the  subject. 
Other  surgeons  have  not  been  so  unfortunate,  and  I  think  that 
as  many  as  20  per  cent  of  these  cases  which  have  been  operated 
upon  have  been  successful.  It  is  an  open  question,  a  question 
that  is  very  open  in  my  mind,  as  to  whether  or  not  it  is  possible 
for  a  patient  to  have  perforation  through  the  ileum,  V/ith  con- 
stant discharge  of  fluid  and  fecal  matter,  and  spontaneous  re- 
covery to  occur.  It  is  held  that  it  is  possible  for  a  piece  of  the 
omentum  to  become  plastically  solid  over  the  perforation  and 
recovery  to  occur,  but  after  the  escape  of  fluid  and  fecal  matter 
into  the  peritoneal  cavity,  we  do  not  have  plastic  peritonitis;  it 
is  septic,  and  is  really  due  to  nature's  making  no  effort  to  stop 
the  perforations.  Twenty  per  cent  could  be  saved,  and  20  per 
cent  is  the  record  of  all  who  have  been  operated  upon  in  all 
stages.  What  would  be  the  result  if  these  had  been  operated 
upon  prior  to  the  advent  of  septic  peritonitis — prior  to  the  dis- 
turbances of  secretions  of  the  peritoneal  cavity?  It  does  not 
seem  such  a  desperate  expedient.  The  perforation  nearly  always 
occurs  within  12  or  18  inches  of  the  ileo-coecal  valve.  This 
operation  does  not  differ  from  any  other  abdominal  operation 
requiring  suture  of  the  intestine,  and  if  done  prior  to  the  advent 
of  suppurative  peritonitis,  it  is  almost  classed  as  simple  laporo- 
tomy  surgically. 


CLINICAL  DEMONSTRATIONS  IN  OPERATIVE  GYNE- 
COLOGY. 


Bv   AuGUSTiN   H.    GoELET,    M.  D,,  Professor  of  Gynecology  in 
the  New  York  School  of  Clinical  Medicine,  etc. 


ABDOMINAL  MYOMECTOMY. 

GENTLEMEN. — Both  operations  today  are  conservative 
operations  upon  the  fibroid  uterus.  The  first  is  an  ab- 
dominal myomectomy,  and  the  second  is  for  ligating  and 
dividing  the  uterine  arteries  through  incisions  in  the  vaginal 
roof  for  an  interstitial  fibroid  growing  in  the  right  anterior 
wall  of  the  uterus.  A  very  short  time  ago  the  uterus  would 
have  been  sacrificed  in  both  these  cases.  I  have  myself  done 
hysterectomy  in  cases  verry  similar  to  these.  But  thanks  to  the 
indefatigable  efforts  of  a  few  conscientious  surgeons  the  possi- 
bility of  conservative  eperations  upon  the  fibroid  uterus  has 
been  clearly  demonstrated.  These  operations  are  the  more  com- 
mendable because,  though  conservative,  in  that  thev  preserve 
the  uterus  and  aim  to  restore  its  functionating  power,  they  are 
radical,  tumor  being  disposed  of.  In  the  one  case  it  is  enucleated 
from  its  bed  in  the  uterine  wall,  and  in  the  other  it  is  made  to 
shrink  and  disappear  by  being  deprived  of  sufficient  circulation 
to  nourish  it. 

The  first  patient  is  now  ready  and  I  will  proceed  with  the 
operation  describing  the  different  steps  as  we  go  along.  The 
abdomen  has  been  opened  and  you  see  the  greatly  enlarge  uterus 
with  its  fibroids  exposed  in  the  incision.  The  patient  is  now 
placed  in  the  Trendelenburg's  posture  so  as  to  get  the  intestines 
away  from  the  field  of  operation.  The  appendages  are  in  good 
condition,  therefore  it  is  worth  while  to  attempt  to  save  the 
uterus.  The  first  step  will  be  to  place  a  rubber  dam  about 
this  uterus  well  down  as  near  the  cervix  as  possible  in  the  same 
manner  as  a  dentist  places  it  about  a  tooth  he  is  about  to  fill. 
By  doing  this  we  shut  off  the  peritoneal  cavity  and  work  as  if  it 
were  out  side  of  it.  This  serves  also  to  keep  the  intestines  out  of 
the  way  and  avoids  wounding  them.  At  the  same  time  I  will 
place  a  rubber  ligature  about  the  cervix  so  as  to  control  bleed- 


444 


G0ELET~ABD01\IINAL  MYOMFX'TOMY. 


ing  should  it  occur,  but  I  will  not  tighten  it  unless  it  becomes 
necessary. 

The  uterus  is  now  drawn  up  as  far  as  possible  so  as  to  facili- 
tate the  work.  You  see  there  are  three  small  growths  project 
ing  from  the  surface  ot  the  uterus  with  broad  bases  for  attach- 
ment, and  one  larger  growth  in  the  posterior  part  of  the  fundus 
which  is  situated  deeply  in  the  wall. 

We  will  attack  the  latter  first  and  see  if  il  can  be  enucleated, 
for  unless  this  can  be  done  a  conservative  operation  must  be 
abandoned  and  the  whole  uter.us  must  be  rvmoved.  I  split  the 
wall  of  the  uterus  over  the  growth  longitudinally  and  make  the 
incision  deep  enough  to  lay  open  the  capsule  of  the  turror. 
These  tumjrs  have  really  no  distinct  capsule,  but  a  line  of  separa- 
tion from  the  uterine  wall  can  usually  be  found  where  detach- 
ment can  be  effected  readily.  The  incision  has  opened  into  the 
tumor  itself  and  you  can  see  it  as  a  distinct  mass  embedded  in 
the  uterine  wall.  Siezing  the  tumor  with  strong  volsella  forceps 
it  is  dragged  upon,  while  with  blunt  curved  scissors  closed  I 
begin  to  detach  it  all  around.  It  is  not  an  easy  matter 
for  the  procedure  consists  in  dragging  the  tumor  literally 
out  of  its  bed.  The  bleeding,  as  you  see,  has  been  insignificant 
and  it  has  not  been  necessary  to  tighten  the  ligature  about  the 
cervix.  Now  the  tumor  has  been  gotten  out  and  there  has  been 
left  behind  a  considerable  cavity  which  must  be  carefully  closed, 
but  before  doing  this  we  will  remove  the  smaller  growths  and 
examine  the  uterine  wall  for  others  which  may  not  be  apparent 
upon  the  surface.  All  that  can  be  detached,  however  small, 
must  be  removed.  These  smaller  growths  which  project  above 
the  surface  are  best  removed  by  seizing  them  at  tke  top  and 
making  a  flap  on  either  side  near  the  base  by  an  incision  through 
the  peritoneurfl  which  is  slipped  down.  The  tumor  is  now 
enucleated  and  peritoneal  flaps  are  brought  together  by  Lembert 
sutures  of  fine  cat  gut,  covering  the  surface  from  which  the 
tumor  has  been  detached.  In  one  place  here  a  small  cavity  has 
been  left  and  this  must  be  closed  in  the  same  manner  as  this 
larger  one  with  buried  cat-gut  sutures. 

Returning  to  the  large  cavity  we  will  now  proceed  to  close 
it.  It  is  very  necessary  to  secure  perfect  coaptation  and  avoid 
leaving  even  the  smallest  pocket  or  space  where  blood  or  serum 


GOELET— ABDOAHNAL  MYOMECTOMY. 

445 

may  collect  and  retard  union.  Uusing  a  fine  cat-gut  suture, 
and  beginning  at  the  bottom,  a  row  of  sutures  are  inserted  from 
side  to  side,  drawing  together  the  base.  When  the  suture  is 
started  no  knot  is  tied  bat  the  end  is  left  long  and  grasped  with 
a  pail  of  haemostatic  forceps  and  held  tight.  When  the  second 
tier  of  sutures  is  inserted  above  the  first,  burying  it,  the  free  end 
of  the  suture  is  cut  off  close.  It  is  better  not  to  leave  a  knot 
buried,  as  much  longer  time  is  required  for  its  absorption.  Tier 
after  tier  of  these  sutures  are  inserted  until  the  cavity  is  com- 
pletely closed,  and  it  now  remains  for  us  only  to  unite  the  peri- 
toneal margins  over  it.  This  is  done  by  the  Lembert  suture 
which  folds  the  edges  in  bringing  the  peritoneal  surfaces  of  the 
margin  ol  the  incision  into  apposition.  The  rubber  doue  is  now 
removed  and  the  abdomen  closed. 

VAGINAL   LIGATION  AND  DIVISION  OF  THE  UTERINE  ARTERIES  FOR  AN 
INTERSTITIAL  FIBROID   IN   THE    ANTERIOR    UTERINE   WALL. 

The  next  operation  is  upon  a  patient  33  years  old  who  has  a 
fibroid  the  size  of  the  fist  in  the  anterior  uterine  wall  which 
interferes  seriously  with  the  bladder.  She  has  been  married 
eight  years  but  has  had  no  children.  The  growth  of  the  tumor 
has  been  slow,  and  she  was  even  ignorant  of  its  presence  until 
she  consulted  a  physician  a  short  time  since  for  the  bladder 
trouble.  I  have  advised  the  operation  I  am  about  to  do  in  this 
case,  because  the  age  of  the  patient  calls  for  preservation  of  the 
uterus  if  the  appendages  are  in  good  condition,  as  my  examina- 
tion leads  me  to  believe  they  are,  and  because  my  experience 
with  this  operation  is  that  when  the  uterine  arteries  are  posi- 
tively obliterated  by  dividing  them  as  well  as  ligating  them,  the 
nutrition  of  the  tumor  is  seriously  interfered  with  and  complete 
and  permanent  atrophy  results.  This  operation  is  considered 
appropriate  in  this  case  because  the  growth  is  small,  interstitial, 
and  so  situated  that  its  principal  sources  of  blood  supply  is  from 
the  uterine  arteries,  I  have  decided  therefore,  to  avoid  for  this 
patient  the  risk  of  an  abdominal  myomectomy  which  would  be 
the  next  choice. 

I  have  every  reason  to  believe,  from  my  past  experience,  that 
this  tumor  will  undergo  complete  atrophy'and  the  uterus,  which 
now  measures  4^  inches,  will  return  to  its  normal  size.  I  lay 
particular  stress  upon    the   necessity    for  dividing   the  arteries 


. -^  aOELET— ABDOMINAL  MYOMECTOMY. 

because  simple  Ifgation  does  not,  with  an}-  degree  of  certiinty-y 
produce  permanent  obliteration  of  the  vessels  owing  to  the  fact 
that  some  broad  ligament  tissue  is  unavoidably  included  in  the 
ligature,  hence  the  destruction  of  the  vessels  is  not  invariably- 
secured,  whereas  if  the  vessel  is  divided  the  circulation  is  per- 
manently arrested. 

The  patient  has  been  prepared  as  carefully  as  for.  vaginal 
hysterectomy,,  and  we  will  begin  by  curetting  the  uterus  very 
carefully  for  in  all  these  cases  there  is-  more  or  less  disease  of 
the  endometrium.  This  done  we  will  tampon  the  uterus  loosely 
v/ith  iodoform  gauze  for  drainage.  In  doing  this  the  cervix  is 
filled  to  the  external  os  and  the  gauze  cut  off  short  so  it  will  not 
project  into  the  vagina  and  interfere  with  the  v/ork  to  be  done 
there.  We  now  insert  a  traction  ligature  through  both  lips  of 
the  cervix  and  drawing  the  uterus  well  down  and  to  the  right. 
We  note  the  location  of  the  cervico-vagina  fold  and  make  there 
a  semi-circular  incision  about  an  inch  and  a  quarter  long  through 
the  vaginal  wall.  With  the  thumb  nail,  bugging  the  side  of  the 
uterus,  the  tissues  are  pulled  up  enlarging  the  opening  and  ex- 
posing the  base  of  the  broad  ligament.  With  the  two  index 
fingers  the  bladder  is  pushed  forward  from  the  base  broad  liga- 
ment in  front  and  the  rectum  is  treed  from  it  behind.  Passing 
the  left  index  finger  now  behind  the  right  in  front  the  base  of  the 
broad  ligament  is  grasped  between  them  and  the  pulsation  of 
the  uterine  artery  is  detected.  Returning  to  the  left  index 
finger  in  position  as  a  guide  the  right  is  withdrawn  and  this 
ligature  carrier,  which  has  a  curve  especially  adapted  for  this 
purpose,  and  carries  a  stout  silk  ligature,  is  inserted  in  front  of 
the  broad  ligament  and  made  to  encircle  the  uterine  artery. 
Catching  the  loop  of  the  ligature  at  the  eye  of  the  ligature  car- 
rier it  is  drawn  through,  and  the  carrier  is  withdrawn,  leaving 
the  ligature  encircling  the  base  of  the  broad  ligament,  and  in- 
cluding the  artery.  The  ligature  must  be  passed  rather  near 
the  uterus  so  as  to  avoid  the  ureter  which  crosses  the  the  artery 
here  about  a  half  an  inch  from  the  uterus.  The  ligature  is  now 
tied  tightly,  the  ends  being  left  long,  temporarily  as  a  guide. 
Drawing  still  more  firmly  upon  the  cervix  with  the  traction 
ligature  and  slightly  upon  the  ligature  securing  the  artery  the 
base  of  the  broad  ligament  is  put  upon  the  stretch.   With  a  pair 


SMALL  POX  IN  STATESVILLE. 

447 
of  stout  scissors  the  tissue  is  divided  between  the  ligature  and 
the  side  of  the  uterus,  and  the  severed  uterine  end  of  the  artery, 
which  as  you  see  spurts  freely,  is  picked  up  with  pressure  forceps. 
This  is  now  tied  with  a  stout  cat  gut  ligature  and  the  forceps  are 
removed.  , 

The  operation  is  now  completed  on  this  side  and  it  remains 
for  us  to  close  the  incision.  One  end  of  the  silk  ligature  around 
the  artery  is  cut  short  and  the  other  left  long,  and  projecting 
down  into  the  vagina  for  drainage,  and  to  remove  the  ligature 
knot  later,  when  it  becomes  detached.  The  incision  in  the 
vaginal  wall  is  closed  by  a  continuous  suture  of  cat  gut. 

The  cervix  is  now  drawn  over  to  the  left  and  the  same  thing 
is  repeated  on  the  other  side.  The  right  uterine  artery  having 
been  secured  and  divided  also,  and  the  vaginal  incision  on  this 
side  closed,  the  vagina  is  filled  loosely  with  iodoform  guaze  as  a 
dressing  for  the  wounds. 

The  after  management  of  this  case  will  be  simple.     The  gauze 

is  left  undisturbed  for  48  hours,    when   it   is  removed  together 

with  that  in  the  uterus.     The  uterine  cavity  is  then  irrigated  and 

usually  the  gauze  is  not  reinserted  in  the  uteris,  but  the  vagina 

is  tamponed  again  for  another  48  hours.      This  is  repeated  until 

about  the  sixth  day,  when  the  gauze  is  removed  and  after  that 

daily  vaginal  douches  of  one  per  cent  markosol  are  given  until 

the  ligatures  come  away.     The  patient   is   confined    to  bed    for 

two  weeks,  and  longer  if  the  ligatures  do  not  come  away  before 

that  time. 

Note, — The  first  patient  made  an  uninterrupted  recovery.  The  second 
case  recovered  from  the  operation  without  any  drawbacks,  and  now  six 
months  after  the  uterus  measures  3  inches  and  no  evidence  of  the  tumor  can 
be  detected  by  the  most  careful  digital  examination. 


Small  Pox  in  Statksvillk. — Dr.  Wertenbaker,  of  the  United 
States  Marine  Hospital  Service,  who  was  ordered  to  Statesville 
to  investigate  the  reported  small  pox  cases,  reports  that  there 
are  elevin  cases,  all  true  small  pox,  among  negroes  in  a  suburb 
of  the  town.  He  pronounces  the  disease  epidemic  and  all  pos- 
sible percautions  will  be  taken  to  prevent  its  spread.  Since  his 
report  fournew  cases  have  developed. 


NORTH  CAROLINA  MEDICAL  JOURNAL. 

ROBERT  D.  JEWETT,  M.D.,  Editor 

DEPARTMENT  EDITORS 

(      H.  T,  Bahnson,  M.D..  Salem,  N.C. 
SURGERY:     \     R.  L.  Gibbon, M.D.,  Charlotte,  N.  C. 

/      J.  Howell  W  ay,  M.D.,  Waynesville,  N.  C. 

NERVOUS  DISEASES:— J.  Allison  Hodges,  M.D.,  Richmond,  Va. 
PRACTICE  OP  MEDICINE.  ]    S-  Westry  Battle,  M.D.,  U.  S.  N. 

niaQT^T^T'T^Tr'a.      i      GEORGE  G.  THOMAS,  M.D.,  Wilmington,  N.  C. 
UBblii-i±liCb.      -j      p^   L.  PAYNE,  M.D.,  Norfolk,  Va. 

(      H.  S.  LOTT,  M.D.,  Winston,  N.  C. 
GYNECOLOGY:     \      J.  W.  Long,  M.D.,  Salisbury.  N.  C. 
(      H.  A.  ROYSTER,  M.D.,  Raleigh,  N.  C. 

PATHOLOGY:— Albert  Anderson,  M.D.,  Wilson,  N.  C. 
PEDIATRICS:— J.  W.  P.  Smithwick,  M.D.,  La  Grange.  N.  C. 
TRANSLATION  AND  FOREIGN  REVIEWS: 
Richard  H.  Whitehead,  M.  D.,  Cha,pel  Hill,  N.  C. 

All  communications,  either  of  a  literary  or  business  nature,  should  be 
addressed  to,  and  any  remittances  by  P.  O.  Order,  Draft  or  Registered  Let- 
ter, made  payable  to  Robert  D.  Jewett,    M.D.,  Winston,  N.  C. 

^MtoriaL 


HUSA. 


A  description  of  this  plant  with  a  report  upon  its  therapeutic 
application  has  recently  been  made  through  the  Texas  Record 
by  Dr.  W.  W.  Winthrop,  of  Fort  Worth.  It  is  found  in  the 
Everglades  of  Florida,  where  it  grows  in  clumps  in  moist,  shady 
places,  particularly  on  the  hummocks  at  the  root  of  the  cabbage 
palm.  The  plant  which  is  yet  unclassified,  is  of  dirty  whitish 
green  color,  with  a  ball  like  white  formation  at  its  summit, 
where  the  flower  should  be,  and  slightly  lobulated,  being  to  all 
appearances  like  a  small  cauliflower.  It  is  claimed  by  the  natives 
that  the  plant  is  a  perfect  antidote  for  all  snake  bites  and  stings 


REVIEWS  AND  BOOK  NOTICES.  ,  .g 

of  insects.  As  an  evidence  of  the  great  reliance  they  place  in  it, 
a  negro,  in  the  presence  of  Dr.  Winthrop,  allowed  himself  to  be 
bitten  several  times  by  moccasins — very  venomous  serpents — and 
after  each  bite  chewed  a  little  piece  of  the  herb,  which  he  said 
counteracted  the  poison.  Certainly  there  was  no  bad  effect  fol- 
lowing. Dr.  Winthrop  says  that  the  plant  is  one  of  the  strongest 
diffusable  stimulants,  acting  immediately.  He  finds  that  it  is 
not  only  a  perfect  antidote  for  all  narcotic  poisons,  but  an  in- 
fallible cure  for  the  opium  habit.  He  says  it  takes  the  place  of 
opium,  sedative  but  not  narcotic,  produces  slight  elation  but  no 
somnolence.  Dr.  Winthrop  reports  that  the  drug  was  tested  by 
several  physicians  in  the  opium  habit  and  their  invariable  testi 
mony  was  that  it  was  a  perfect  success. 

Should  longer  experimentation  prove  the  constancy  of  Dr. 
Winthrop's  results  with  this  plant,  it  will  be  a  most  useful  ad- 
dition to  the  materia  medica;  but  we  are  afraid  that  such  will 
not  be  the  case.  There  is  too  much  tendency  to  allow  our  en- 
thusiasm to  run  awav  with  us,  when  we  think  we  see  an  oppor- 
tunity to  present  something  new  to  the  profession.  We  would 
not  advise  our  readers  to  buy  exclusive  rights  to  use  this  new 
drug,  with  the  idea  of  establishing  sanatoria  for  the  cure  of  the 
opium  habit. 


1Re\)iew6  anb  'Boo\{  IRotlcee. 


Elements  of  Latin. — For  students  of  Medicine  and  Pharmacy. 
By  George  D.  Crothei-s,  A.  M.,  M.  D.,  Teacher  of  Latin  and  Greek  in 
the  St.  Joseph  (Me.)  Hig^h  School;  Formerly  Professor  of  Latin  and 
Gi-eek  in  the  University  of  Omaha;  and  Hiram  H,  Bice,  A.  M.,  Instruc- 
tor in  Latin  and  Greek  in  the  Boy's  High  School  of  New  York  City. 
5i  X  71  inches.  Pages  xii-242.  Flexible  Cloth,  $1.25  net.  The  F.  A. 
Davis  Co.,  Philadelphia,  1898. 

There  is  a  growing  tendency  among  modern  medical  educators 
to  require  of  matriculates  a  more  thorough  general  education. 
All  of  the  high  grade  colleges  of  the  present  day  require  a  mod- 
erate l^nowledge  of  latin,  but  there  was  great  laxity  in  regard 
to  this  preliminary  education  until  within  the  past  few  years. 
The  volume  before  us  will  be  found  useful  to  students  as  well 
as  to  general  practitioners,  who  have  not  been  taught  latin,  or 


^co  REVIEWS  AND  BOOK  NOTICES. 

whose  busy  lives  have  allowed  them  to  become  rusty.  It  is  not 
intended  as  an  introduction  to  the  latin  language  and  literature, 
but  as  an  aid  in  the  acquirement  of  such  knowledge  of  latin  as 
will  be   necessary   in    the  study  of  medicine  and  pharmacy. 

Outlines  of  Rural  Hygiene.— For  Physicians,  Students,  and 
Sanitarians  By  Harvey  B.  Bashore,  M.  D.,  Inspector  for  the  State 
Board  of  Health  of  Pennsylvania.  With  an  Appendix  on  the  Normal 
Distribution  of  Chlorine  by  Prof.  Herbert  E.  Smith,  of  Yale  University. 
Illustrated  with  Twenty  (20)  Engravings.  5i  x  8  inches.  Pages  vi-84. 
Extra  Cloth,  75  cents  net.     The  F.  A.  Davis  Co.,  Philadelphia,  1898. 

This  little  volume  of  seventy-five  pages  if  read  by  the  class  of 
people  for  whom  it  was  intended,  would  do  much  to  enlighten 
them  in  regard  to  the  proper  sanitation  of  their  homes.  It  very 
properly  starts  out  with  a  chapter  on  drinking  water,  showing 
the  harmfulness  of  the  ordinary  well,  and  advocating  the  cistern. 
We  do  not  endorse  th*e  author's  idea  of  dividing  the  cistern  and 
making  one  part  of  it  the  filter.  It  is  much  better  and  cheaper 
to  have  the  filter  outside,  where  it  can  be  easily  renewed  or 
cleaned.  While  it  may  be  very  well  in  the  section  where  the 
author  lives  to  catch  water  for  the  cistern  throughout  the  year, 
that  is  not  a  good  plan  for  this  section,  but  the  cistern  should  be 
large  enough  to  allow  the  supply  to  be  cut  off  entirely  through 
the  summer  months.  Too  much  stress  cannot  be  laid  upon  the 
importance  of  keeping  clean  the  roof  from  which  the  water  is 
collected,  the  filter,  and  the  cistern  itself. 

The  remaining  chapters  deal  with  the  disposal  of  waste,  the 
heating  and  ventilation  of  dwellings,  the  care  of  the  soil  and  the 
disposal  of  the  dead.  The  book  would  make  a  good  one  to  place 
in  the  hands  of  the  laity. 

Treatise  on  the  Diseases  of  Women. — For  the  Use  of  Stu- 
dents and  Practitioners.  By  Alexander  J.  C  Skene,  M.  D. ,  LL.  D.; 
Professor  of  Gynecology  in  the  Long  Island  College  Hospital,  Brook- 
lyn, N.  Y.;  formerly  Professor  of  Gynecology  in  the  New  York  Post 
Graduate  Medical  College;  Gynecologist  to  the  Long  Island  College 
Hospital;  etc.,  etc.  Third  Edition,  enlarged  and  revised.  With  290 
engravings  and  four  plates  in  colors.  One  large  handsome  royal  oc- 
tave volume  of  992  pages.  Price  by  subscription,  cloth  $5.00.  P.  Ap- 
pleton  &  Co.,  New  York,  1898. 

A  comparison  of  this  edition  with  its  predecessors  will  give  a 
good  idea  of  the  advances  that  have  been  made   in   this   branch 


REVIEWS  AND  BOOK  NOTICES.  .  -  ^ 

of  medicine  during  the  past  decade.  Many  additions  in  the  way 
of  treatment  have  been  made  in  preparing  this  last  edition,  and 
much  has  been  omitted.  Dr.  Skene  is  not  an  extremest  in  either 
direction  and  his  teaching  may  be  accepted  by  the  general  prac- 
titioner as  based  upon  practical  experience.  The  plan  adopted 
in  the  earlier  editions  of  the  work  of  appending  to  each  chapter 
illustrative  cases,  showing  the  results  obtained  in  the  treatment 
of  various  conditions,  has  been  retained  in  the  present  edition. 
Improved  instruments  take  the  place  of  obsolete  ones,  and  new 
illustrations  which  give  a  better  understanding  of  the  text  have 
been  added.  Among  the  more  important  additions,  and  the  one 
which  will  attract,  probably,  the  greatest  share  of  attention,  is 
the  author's  method  of  arresting  hemorrhage  by  compression 
and  electric  heat.  By  this  method  "a  portion  of  the  end  of  a 
vessel,  or  mass  of  tissue  containing  bleeding  vessels,  is  seized  in 
a  forceps  or  clamp  and  firmly  compressed,  and  while  under 
pressure  heat  is  applied  to  the  instrument  to  dessicate  or  dry  the 
parts  but  not  to  char  them.  In  this  way  the  walls  of  the  vessels 
become  united  and  hemorrhage  is  certainly  prevented."  The 
author  has  had  made  a  forceps  one  of  the  jaws  of  which  is  ser- 
rated as  in  the  ordinary  artery  clamps,  while  the  other  is  smooth 
and  provided  with  a  chamber.  The  electric  current  is  carried 
through  a  copper  wire  along  one  handle  of  the  forceps,  and 
passes  through  a  platinum  wire  which  is  zig-zagged  across  this 
chamber.  The  resistance  offered  by  the  platinum  wire  produces 
the  necessary  heat  to  dessicate  the  tissues  held  in  the  grasp  of 
the  forceps.  Dr.  Skene  believes  that  this  method  should  super- 
sede the  ligature  in  all  surgical  operations  and  says  of  it  "the 
advantages  which  may  be  fairly  claimed  for  this  way  of  control- 
ling bleeding  in  surgery  are,  that  it  is  certain  and  reliable  in 
closing  isolated  vessels  or  those  imbedde  din  masses  of  tissue, 
like  an  ovarian  tumor  pedicle,  for  example,  or  the  uterine  and 
and  ovarian  arteries  in  the  broad  ligament.  At  the  same  time 
that  bleeding  is  arrested  all  lymphatics  are  sealed  up,  which 
prevents  septic  absorption.  Nerves  that  accompany  the  vessels 
are  immediately  and  completely  devitalized,  and  hence  there  are 
less  pain  and  irritation  in  the  stump.  The  heat  employed  steri- 
lizes the  part  involved,  and  therefore  the  operation  is  perfectly 
aseptic." 


.^2  CORRESPONDENCE. 

There  is  also  a  new  and  interesting  chapter  describing  the  use 
of  the  cystoscope  and  endoscope. 


Correeponbence. 


FURTHER  DISCUSSION  OF  DR.  R.  L.  PAYNE'S  PAPER 
ON  ABORTION. 


Editor  N.  C.  Medical  Journal: 

Being  compelled  to  leave  for  home  before  the  the  reading  of 
Dr.  Payne's  paper  on  abortion,  I  had  not  the  opportunity  to 
discuss  it  in  the  meeting  of  the  Society,  but  I  hope  the  following 
few  remarks  may  not  be  out  of  place  at  this  late  hour. 

The  paper  of  Dr.  Payne  is  good.  There  are,  however,  some 
points  upon  which  I  do  not  agree  with  him.  First  as  to  medica- 
tion with  "large  dofes"  of  viburnum  prunifolium.  If  his  obser- 
vation has  been  at  all  like  mine,  he  knows  that  out  of  twenty 
women,  there  will  be  possibly  one  who  can  take  more  than  the 
first  dose  of  black  haw,  without  nausea  and  vomiting,  both  of 
which  favor  haemorrhage,  and  mcrease  exhaustion.  Some  cases 
abort,  others  don't,  medication  amounts  to  little,  save  to  quiet 
mental  worry,  or  to  keep  moral  control  of  the  patient. 

Abortion  is  a  surgical  accident,  and  may  have  for  its  cause  either 
external  or  internal  forces.  His  plea  for  care  in  the  use  of  the 
curette,  is  most  excellent,  save,  that  in  making  his  exception, 
he  drops  the  keystone  from  the  arch,  and  destroys  the  whole 
structure.  He  says,  "while  I  believe  there  is  a  field  for  the  use 
of  the  curette  in  abortion,  I  believe  it  is  strictly  limited  to  septic 
cases,  and  those  in  which  the  products  of  cenception  having 
escaped,  haemorrhage  is  kept  up  by  retained  placental  frag- 
ments." 

Now,  picture  the  pathology  of  a  septic  uterus,  with  infiltrated, 
softened,  and  even  friable  walls,  and  you  cannot  fail  to  realize 
the  danger  of  perforation  or  other  trauma  to  these  walls,  from  a 
feelingless,  metal  instrument,  blindly  at  work  in  a  dark  cavity, 
whether  such  instrument  be  in  either  skilled  or  unskilled  hands. 
Therefore,  in  these,  of  all  cases,   there  is  most  danger  from  the 


CURRENT  LITERATURE. 

453 
use  of  the  curette.  Remove  the  remaining  placental  tissue  with 
the  cushioned  end  of  a  clean  finger,  pressing  the  uterus  down 
with  the  left  hand  above  the  pubis,  irrigate  the  cavity  of  the 
uterus  with  half  gallon  of  hot  water,  reduced  to  such  tempera- 
ture as  the  hand  will  bear  with  comfort,  using  a  Davidson's  bulb 
syringe,  with  the  end  of  the  nozzle  presenting  within  the  inter- 
nal OS,  bathe  the  patient,  and  lift  her  into  a  dry  clean  bed,  with 
fresh  clothes,  and  give  her  a  chance. 

Salem,  N.  C.  H.    S.   Lott,  M.  D. 


1Revie\V0  of  Current  Xitcrature. 


GYNECOLOGY  AND  ABDOMINAL  SURGERY. 


IN  CHARGE  OF 

H.  S.  Lott,  M.  D.,  J.  W.  Long,  M.  D. 

Hubert  A.  Royster,  M.  D. 


A  New  Operation  for  Repair  of  the  Perin.eum  and  Poster- 
ior Vaginal  Wall. — Dr.  Frank  S.  Andrews  of  Chicago,  (in  the 
American  Gynaelogical  and  ObstetricalJournal,  March  1898,  )describes 
in  full  a  procedure  which  bids  fair  to  reflect  much  credit  upon  its 
originator,  and  give  much  relief  to  suffei'ing  women.  It  is  valuable 
because  it  is  practical,  and  applicable  to  a  large  number  of  cases  in 
which  the  need  is  to  restore  the  supporting  power  of  the  perinaeum  and 
posterior  wall. 

It  is  to  the  courtesy  of  the  Journal  editor,  Dr.  J.  D.  Emmet  that  I 
am  indebted  for  the  illustrating  cuts,  the  plates  for  which  he  loaned 
most  willingly. 

Dr.  Andrews  first  pictures  the  anatomy  of  the  parts,  impressing  the 
supporting  office  of  the  perinaaum  and  posterior  wall,  and  the  need  of 
support  for  the  uterus;  this  support  being  often  destroyed  during  labor 
and  allowing  a  descent  of  this  organ.  Holding  that  the  ideal  operation, 
when  found,  will  correct  this  trauma  to  the  vaginal  outlet,  and  with  it 
the  prolapse,  retroversion,  rectocele  or  cystocele. 

His  operation  is  as  follows:  The  anesthetized  patient  is  put  in  the 
lithotomy  position,  the  labia  separated,  and  the  sides  of  the  vaginal 
orifice  retracted  with  sharp  hooks  at  or  above  the  lower  myrtiform  car- 
uncles. These  hooks,  when  brought  together,  mark  the  upper  external 
angle  of  the  new  perinEeum.     It  is  desirable  that  they  be  placed  as  high 


454 


CURKENT  LITEKATUUE. 


as  may  be,  consistently,  with  leaving  a  propei-  vaginal  orifice,  for  by 
this  means  the  anterior  vaginal  wall  and  the  bladder  will  be  best  sup- 
ported.    The  I'etracting  hooks  being  heeld  by  an  assistant,  so  that  the 


U 


\\ 


Fig.  I — Extended  triangle  denuded.        Fio.  2 — Finger  tip  introduced  under 

mucous   membrane   of  posterior 
vaginal   wall. 

tissues  between  them  are  tense,  make  an  incision  through  the  membrane 
extending  from  hook  to  hook.  With  this  incision  as  a  baseline,  denude 
an  external  triangle  with  its  apex  at  a  selected  point  anterior  to  the  anus. 

U 


Fig.  3 — Finger  pushed  up  to  cervix,      Fig.  4 — Both  tunnels  formed.   Incision 
making  a  tunnel  under  mucous  ot  mucous  membrane  from  vulva 

membrane.  to  cervix  in  dotted  line. 

This  point  is  determined  by  the  amount  of  perineal  laceration. 

Up  to  this  stage  the  operation  presents  no  new  feature,  but  I  think 


CURRENT  LITERATURE. 


455 


that  the  next  step,  whatevei'  its  merit,  at  least  by  its  novelty,  Justifies 
the  title  of  this  paper. 


Fi;.  5 — Retraction  of  mucous  mem-         Fig.  6 — Crown  stitch  passed  around 
brane     leaves     denuded    surface.  the  mucous  membrane  tongue. 

Tongue  of  mucous  membrane  is 
attached  by  its  centre  line  to  the 
crest  of  the  rectocelc. 

The  cut  edge  of  vaginal  mucous  membrane  forming  the  base  of  the 
denuded  triangle  is  now  seized  three  quarters  of  an  inch  to  the  left  of 
t'le  raphe  with  forceps,  and  raised,  so  that  the  tip  of  the  index  finger 


Fig.  7— Crown  stitch  tied.  .One  thread         Fig.  8 — Vaginal  stitches  all  tied. 

from  the  knot  left  long,   to  be  used  Skin  stitches  passed    but    not 

as  a  guide  in  removing  stitch.  tied, 

can  be  introduced  beneath  it.  To  do  this  it  is  sometimes  necessary  to 
clip  with  scissors  some  bands  ot  cicatricial  submucous  tissue  at  the 
edge  of  the  membrane.     The  index  finger  is  now  easily  pushed  upward 


.-g  CURRENT  LITERATURE. 

beneath  the  mucous  membra-nc*  of  the  posterior  vaginal  wall  until  the 
tip  of  the  finger  is  beneath  and  behind  the  cervix  uteri,  and  separated 
from  it  by  mucous  membrane. 

It  is  desirable  that  the  deep  end  of  the  tunnel  thus  formed  should  be 
nax'row,  but  the  external  portion  may  be  increased  in  calibre  by  a  lat- 
eral movement  of  the  finger,  as  much  as  desired. 

Repeating  this  procedure  on  the  opposite  side  of  the  median  line,  it 
will  I'eadily  be  seen  that  the  vaginal  mucous  membrane  has  been  lifted 
from  the  reco-vaginal  septum,  but  has  retained  its  attachment  through- 
out the  median  line  along  the  crest  of  the  rectocele.  Throughout  this 
procedure  it  is  imperative  that  the  tip  of  the  finger  be  kept  close  to  the 
middle  line.  Neglect  of  this  precaution  will  result  in  stripping  mucous 
membeane  from  the  lateral,  or  even  from  the  anterior  wall  of  the 
vagina. 

Selecting  a  pair  of  straight  scissors,  cut  the  lifted  mucous  membrane 
of  the  posterior  vaginal  wall  on  the  right  side,  from  vulva  to  cervix. 
This  is  best  done  by  using  the  finger  in  the  artificial  canal  as  a  guide 
for  the  scissors,  and  cutting  the  mucous  membrane  throughout  the 
entire  length  of  the  canal.  There  is  considerable  opportunity  for  dis- 
cretion on  the  part  of  the  operator  in  determining  the  exact  line  of  in- 
cision, but  in  general  it  may  be  said  that  it  will  extend  from  a  point 
near  the  lower  myrtiform  caruncle  to  a  point  a  quarter  or  a  third  of 
an  inch  from  the  middle  line,  beneath  and  behind  the  cervix  utei'i.  Re- 
peat this  operation  on  the  left  side. 

A  feature  of  the  operation  which  doubtless  has  attracted  your  at- 
tention is  the  fact  that  these  two  incisions,  so  widely  separated  at  the 
vulva,  approach  so  near  to  one  another  under  the  cervix,  and  that  the 
vaginal  mucous  membrane  between  the  lines  of  incision  is  a  triangle 
with  its  base  at  the  vulva  and  its  incomplete  apex  under  the  cervix. 
Remember,  also,  that  this  triangle  is  attached  from  base  Co  apex  along 
the  median  line  of  the  vagina.  The  disposition  to  be  made  of  this 
piece  of  mucous  membrane,  with  its  attachment  to  the  rectocele  is  the 
principal  feature  of  the  operation. 

Notice  further,  that  although  the  area  of  mucous  membrane  between 
the  lines  to  be  incised  is  triangular,  its  shape  changes  instantly  when 
the  incisions  have  actually  been  made.  This  is  due  to  the  natural  re- 
traction which  takes  place  in  the  membrane.  Its  appearance  now  is 
that  of  a  tongue  of  mucous  membrane  upon  the  rectocele.  The  tissues 
at  the  side  of  the  vagina  also  retracted.  The  shrinkage  of  the  tissues 
leaves  the  floor  of  the  vagina  denuded  in  two  triangles  separated  by 
the  tongue  of  mucous  membrane.  The  incisions  cut  a  small  branch  of 
the  vaginal  artery  on  each  side,  about  an  inch  and  a  quarter  from  the 
vulva.  The  slight  bleeding  is  controlled  by  forceps  appled  for  a  few 
moments,  without  ligature. 

The  parts  are  now  ready  for  the  sewing.  In  the  passage  and  tying  of 
the  first  stitch  will  be  found  the  essence  of  the  operation. 


CURRENT  LITERATURE. 

457 

The  procedures  just  described  were  devised  as  the  quickest  and  best 
way  of  preparing  the  parts  for  this  crown  stitch,  which  will  be  so 
passed  as  to  surrond  the  tongue  of  mucous  membrane  and  draw  it  up 
under  the  cervix  in  folds,  thus  straightening  the  anterior  rectal  wall.  It 
is  done  a,s  follows: 

Select  a  stout  needle,  short  enough  to  be  easily  turned  in  the  vagina. 
Cause  it  to  enter  the  mucous  membrane  of  the  left  side  of  the  vaginal 
fornix,  beside  and  behind  the  cervix,  i.  e.,  just  beyond  the  inner  end  of 
the  long  incision  on  the  left  side,  and  beside  the  base  of  the  mucous 
membrane  tongue.  Let  the  needle  go  deeply  into -the  submucous  tissue, 
and  bring  it  out  in  the  denuded  surface,  near  the  cervix.  Now  let  the 
needle  pass  around  the  tongue,  catching  up  the  mucous  membrane  at 
several  points  so  that  the  thread  will  surround  it  like  a  purse  string. 
Bring  the  needle  out  on  the  right  side  at  a  point  corresponding  to  the 
point  of  entry  on  the  left. 

'  Traction  exerted  on  both  ends  of  this  stitch  will  cause  the  mucous 
membrane  tongue  to  be  folded  up  in  a  wrinkled  mass  underthe  cervix. 
Tie  the  stitch  so  that  the  knot  lies  in  front  of  the  mass.  If  the  tension 
on  the  rejtum  is  too  great,  a  few  fibers  under  the  tip  of  the  tongue  may 
be  clipped  wixh  scissors.  The  anterior  rectal  wall  is  now  straight.  The 
rectocele  has  disappeared,  and  is  no  longer  a  factor  in  the  case.  The 
remaining  denuded  surface  now  has  the  form  of  a  triangle,  and  is  to 
be  closed  in  the  usual  way.  As  the  closure  is  effected,  stitch  by  stitch, 
the  cervix  is  forced  further  and  further  upward  and  backward  by  the 
increased  resiliency  of  the  pelvic  floor  and  the  reduction  in  its  projection, 
while  the  same  factors  support  the  anterior  vaginal  wall. 

I  am  in  the  habit  of  tying  each  stitch  as  soon  as  passed,  and  of  cut- 
ting oflF  the  left  hand  end  close  to  the  knot,  leaving  the  right  hand  end 
long,  as  a  guide  to  the  knot  to  facilitate  its  removal. 

In  from  two  to  three  weeks  I  remove  the  stitches  with  my  stitch  cutter. 
The  guiding  strand  of  silkworm-gut  is  placed  in  the  small  hook  near 
the  jaws  of  the  instrument.  The  instrument  slides  down  upon  the  knot, 
cuts  and   removes   it. 

in  placing  the  wrinkled  mass  of  tissue  under  the  cervix,  it  was  not 
the  intention  that  this  should  constitute  the  uterine  support.  Neverthe- 
less, it  does  offer  considerable  temporary  sujiport  to  the  cervix  and  to 
whatever  extent  it  does  this  it  is  of  value. 

The  real  value  of  the  operation  is  in  the  fact  that  by  this  method  the 
denudation  is  made  quickly,  easily,  and  almost  bloodlessly,  and  that 
then,  with  one  stitch,  the  rectocele  is  obliterated,  and  the  denuded  sur- 
face brought  into  proper  position  for  closure. 

The  suppoi't  offered  by  the  folded  mass  underthe  cervix  is  transient, 
the  tissue  shrinks  or  is  absorbed,  and  at  the  end  of  three  to  four  weeks 
it  has  lost  three-quarters  of  its  bulk  and  all  of  its  wrinkles,  so  that  its 
surface  is  a  smooth  dome.  In  another  month  or  two  it  is  not  to  be 
found.     The  vaginal  mucous   membrane  is  smooth  and  level  over  the 


^rg  NOTES  AND  ITEMS. 

spot,  as  is  also  the  rectal  mucous  membrane  of  its  under  surface. 

As  the  prime  feature  in  this  operation  is  the  obliteration  of  the  rec- 
tocele,  it  is  self-evident  that  it  is  not  applicable  to  cases  in  which  no 
rectocele  exists,  namely,  slight  lacerations  of  the  perinaeum  on  the  one 
hand,  and  complete  tears  through  the  sphincter  ani  on  the  other. 

The  after-treatment  is  the  same  as  follows  any  perinatal  operation. 
The  bladder  and  rectum  should  be  kept  empty  and  the  wound  kept 
sterile. 

Immediately  after  the  operation  I  use  sterilized  boric  acid  freely, 
placing  about  an  ounce  in  the  vagina  and  another  ounce  in  the  dressing- 
over  the  vulva  and  perineum. 

The  steps  of  the  operation  may  be  summed  up  as  follows: 

1.  The  labia  are  separated  and  sharp  retracting  hooks  on  the  myrti- 
form  caruncles  expose  the  field  of  operation. 

2.  An  external  triangle  is  denuded  on  the  skin  sui'face,  as  in  Em- 
met's operation. 

3.  Keeping  to  the  left  of  the  median  line,  the  finger  is  then  passed 
upward  under  the  mucous  membrane  of  the  posterior  vaginal  wall  to 
a  point  beneath  the  cervix. 

4.  Repeating  this  on  the  right  side,  we  have  two  parallel  sinuses  ex- 
tending the  whole  length  of  the  recto-vaginal  septum. 

5.  Tne  mucous  membrane  is  now  cut  with  scissors,  from  vulva  to 
cervix,  over  each  new  sinus.  This  leaves  a  tongue  of  mucous  membrane 
attached  to  the  middle  line  of  the  vagina. 

6.  Secure  the  small  spurting  artery  in  each  incision  with  forceps. 

7.  The  first  stitch  is  so  passed  as  to  surround  the  tongue  and  draw  it 
back  under  the  cervix. 

8.  The  remaining  stitches  are  easily  passed,  as  in  the  repair  of  a 
i-ecent  laceration. 

The  results  have  been  thoroughly  satisfactory.  I  have  done  this 
operation  on  more  than  fifty  patients  with  uniformly  good  results,  as 
far  as  I  havebeen  able  to  follow  the  cases,  In  some  cases  suplemental 
operations  were  made  at  the  same  time,  as  anterior  colporrhaphy  and 
suspensio  uteri.  H.  S.  L. 


IRotee  anb  Htcme. 


Yellow  Ffvek  at  Mc Henry,  Miss. — Yellow  fever  has  already 
appeared  at  Mc  Henry,  Mississippi,  and  quarintine  has  been 
established  against   Harrison,  Jackson    and  Hancock  counties. 

Acting  Assistant  Surgeon  John  Blair  Gibbs. — The  med- 
ical coips  of  the  Army  has  received  its  first  fatality  in  the  death 


NOTEES  AND  ITEMS. 

459 

of  Surgeon  Gibbs,  who  was  killed  by  a  Spanish  bullet  during  a 
night  engagement  between  the  United  States  Marines  who  were 
landed  at  Guantanamo  June  9th,  and  Spanish  guerillas  and  reg- 
ulars. Dr.  Gibbs  was  a  graduate  of  the  University  ot  Virginia, 
and  had  been  practicing  in  New  York  City  several  years.  When 
the  call  for  acting  assistant  surgeons  was  made  he  responded 
and  was  ordered  to  Key  West.  He  was  forty  years  of  age  and 
unmarried. 

University  of  Virginia— The  Final  exercises  at  this  insti- 
tution were  opened  Sunday,  June  12,  by  the  dedication  of  t  he 
Y.  M.  C.  A.  hall  in  the  new  building  which  has  replaced  the  one 
destroyed  by  fire  a  year  ago. 

The  Doliber-Goodale  Co.,  announce  that  the  name  of  their 
company  has  been  changed  to  "Mellins  Food  Company  of  North 
America."  There  has  been  no  change  in  the  organization  of 
the  Company  nor  in  its  management;  the  change  is  a  change  of 
name  only. 

Bayer's  Pharmaceutical  Prkperations. — The  agency  for 
these  preparations  has  been  transferred  from  Mess.  Schieffelin  & 
Co.,  to  Farbenfabriken  of  Elberfeld  Co.,  40  Stone  St.,  New 
York,  to  whom  all  correspondence  relating  to  these  preparations 
should  be  addressed. 

Resignations  from  Bellevue  Hospital  Medical  College. — 
The  following  gentlemen  have  resigned  from  the  faculty  of  the 
Bellevue  Hospital  Medical  College:  Drs.  Austin  Flint,  pro- 
fessor of  physiology;  Frederic  S.  Dennis,  professor  of  principles 
and  practice  of  surgery;  and  Samuel  Alexander,  professor  of 
genito- urinary  surgery. — Medical  Record. 


Spain's  Responsibility. — Dr.  John  B.  Hamilton,  in  an  ad- 
dress at  the  Physicians'  Club,  said  that  the  danger  to  our  troops 
from  yellow  fever  in  Cuba  has  been  exaggerated.  He  blames 
Spain  for  its  neglect  in  permitting  Havana  to  be  such  a  pest, 
and   declares   that   if  the   British   could   drive  the  disease  from 


.gQ  NOTES  AND  ITEMS. 

Kingston,    Jamaica,    the   Spanish  surely   could,    it   they  would, 
from  Havana. — American  Medico- Surgical  Bulletin. 

Fake  Doctors. — Two  physicians,  Drs.  Simpson  and  Ghiselin, 
of  the  City  Hospital  of  St.  Louis,  Mo.,  are  stated  by  the  papers 
of  that  city  to  be  in  consternation  over  a  huge  joke  that  is  being 
played  upon  them  by  persons  who  resemble  them  in  personal 
appearance.  During  their  absence  from  the  hospital  their  doubles 
are  said  to  come  in  and  give  orders  to  nurses  and  attendants, 
examine  patients,  enter  their  rooms,  and  appropriate  cigars  and 
the  like.  An  effort  is  being  made  to  catch  them,  but  so  far 
without  success. — America?!  Medico-Surgical  Bulletin. 

Nathan  Lewis  Hatfield  Prize  for  Original  Research  in 
Medicine. — The  College  of  Physicians  in  Philadelphia  announ- 
ces through  its  Committee  that  the  sum  of  Five  Hundred  Dol- 
lars will  be  awarded  to  the  author  of  the  best  essay  in  competi- 
tion for  the  above  prize. 

Subject:  "A  Pathological  and  Clinical  Study  of  the  Thymus 
Gland  and  its  Relations." 

Essays  must  be  submitted  on  or  before  January  ist,  1900. 
Addrees,  J.  C.  Wilson,  M.  D.,  Chairman,  219  South  Thirteenth 
Street,  Philadelphia,  Pa. 

The  Action  of  Tobacco  on  the  Sight. — According  to  Medi- 
cine modern  {Lyon  medical,  May  15th),  not  one  out  of  a  hundred 
and  fifty  employees  in  an  American  tobacco  factory  exhibited, 
on  examination,  normal  vision.  All  of  the  employees  either 
smoked  or  chewed.  In  forty-five  cases  the  acuteness  of  vision 
was  perceptibly  lessened ;  in  thirty,  dyschromatopsy  was  very 
pronounced — to  some,  red  appearing  as  brown  or  green;  to 
others,  green  seeming  to  be  blue  or  orange.  The  majority  were 
incapable  of  distinguishing  a  white  point  in  the  centre  of  a  black 
carton. — Netu  York  Medical  Journal. 

Citric  Acid  in  the  Propaylaxis  of  Whooping-cough. — Ac- 
cording to  the  Therapist  for  May  14th,  Moncorvo  Filho,  of  Rio 
Janeiro,  states  that  the  special  bacillus  of  pertussis  is  destroyed 
in  its  chosen  home,  the  larynx,  by  swabbing  the  periglottic 
region  with  a  ten-per-cent    solution   of   citric  acid  with   simple 


NOTES  AND  ITEMS.  .5  j 

syrup.  It  also  constitutes  an  effective  prophylaxis  against  in- 
fection. He  succeeded  in  preventing  the  disease  in  many  chil- 
dren living  with  others  infected,  by  this  means,  or  merely  by 
the  administration  of  small  quantities  of  citric  lemonade  during 
the  day.  He  considers  resorcin  and  asaprol  the  most  effective 
of  other  remedies. — New  York  Medical  Journal. 

Concentration  of  Diphtheria  Antitoxin. — A  practical  dis 
advantage  in  the  use  of  diphtheria  antitoxin  is  the  large  amount 
of  serum  that  has  sometimes  to  be  injected.  Buiwid  {Dent.  med. 
IVoeh.,  February  24th)  has  discovered  a  method  of  concentration 
by  which  1,000  units  can  be  injected  with  1%  to  3  Cc.  of  serum. 
The  details  of  the  preparation  consists  in,  first,  freezing  the  serum 
gradually,  so  that  white  crystals  begin  to  fotm  in  the  yellow  fluid. 
Eventually  the  yellow  fluid  also  freezes.  The  resulting  solid 
mass  is  next  allowed  to  thaw  gradually.  The  yellow  fluid  is  the 
first  to  appear,  and  consists  of  albumen  and  salts;  the  white 
crystals  are  the  next  to  thaw.  The  two  fluids  now  remain  sepa- 
rate, the  yellow  being  below  and  the  white  above.  The  immu- 
nizing quality  is  only  contained  in  the  yellow  fluid,  and  it  ap- 
pears to  be  twice  as  strong  as  it  was  before  being  frozen. — 
American  Druggist. 

Amylolytic  Ferments. — Wyatt  Wingrave,  M.  R.  C.  S.  Eng. 
after  a  crucial  comparative  examination  of  many  malt  extracts 
and  of  Taka  diastase,  the  tests  being  conducted  both  chemically 
and  clinically,  summarizes  briefly:  i.  That  Taka  diastase  is  the 
most  powerful  of  the  starch  or  diastatic  ferments  and  the  most 
reliable  since  it  is  more  rapid  in  its  action — i  e.,  "it  will  convert 
a  larger  amount  (of  starch)  in  a  given  time  than  will  any  other 
amylolytic  ferment."  2.  That.it  seems  to  be  retarded  in  its  di- 
gestive action  by  the  presence  of  the  organic  acids  (butyric,  latic, 
acetic),  and  also  by  tea,  coffee  and  alcohol,  than  are  saliva  and 
the  malt  extracts.  This  is  an  important  point  in  pyrosis.  3. 
That  all  mineral  acids,  hydrochloric,  etc.,  quickly  stop  and  per- 
manently destroy  all  diastatic  action  it  allowed  sufficient  time 
and  if  present  in  sufficient  quantities.  4.  That  Taka  diastase 
and  malt  diastase  have,  like  ptyalin,  no  action  upon  cellulose 
(uncooked  starch).  All  starch  food  should  therefore  be  cooked 
to  permit  of  the  starch  ferment  assisting  Nature  in  this  function. 


•  gj  READING  NOTICES. 

NECROLOGY 


Dr.  Frank  W.  Brown,  aged  38  years,  at  Greenville,  N.  C., 
May  15.  Dr.  Brown  was  educated  at  the  State  University. 
He  began  studying  medicine  under  Dr.  C.  J.  O'Hagan  in 
Greenville  and  later  took  athorc.ugh  course  at  Bellevue  Medical 
College,  New  York.  After  graduating  at  Bellevue  he  returned 
to  Greenville  and  formed  a  copartnership  with  Dr.  O'Hagan  for 
the  practice  of  his  profession.  So  thorough  was  his  knowledge 
of  medicine  and  surgery  that  in  a  short  while  he  had  taken  rank 
among  the  leaders  in  his  profession.  All  along  he  enjoyed  a 
large  and  wide  spread  practice,  and  for  several  terms  he  held  the 
position  of  County  superintendent  of  Health. 

In  1885  Dr.  Brown  married  Miss  Camille  Latham,  oldest 
daughter  of  the  late  Maj.  L.  C.  Latham.  He  leaves  a  widow 
and  four  children. 

He  was  a  member  of  the  North  Carolina  Medical  Society 
sines  1884. 


TReaMna  IRoticcs. 


Infant  Feeding. — After  years  of  experience  in  Infant  Feed- 
ing, I  am  obliged  to  say  that  Mellin's  Food  and  fresh  cow's 
milk  serveme  best.  Cow's  milk  contains  a  large  amount  of 
caseine  (curd)  which  most  infants  can  not  digest;  this  causes 
curdy,  lumpy  diarrhoea  and  emaciation.  Mellin's  Food  so  acts 
on  the  caseine  that  it  can  be  easily  digested  and  thereby  prepare 
the  best  artificial  food  I  have  ever  used. 

C.  C.  Morrison,  M.  D. 
in  '■^Annals  of  Gynecology  cend Faediatry." 

Sanmetto  in  Cystitis,  Prostatitis  and  Irritable  bladder. 
— I  have  been  using  Sanmetto  in  my  practice  for  two  or  three 
years.  I  have  used  it  in  a  good  many  cases  of  cystitis,  prosta- 
titis and  in  all  cases  of  irritable  bladder,  with  the  most  gratifying 
results. 

R.  T.  HocKER.  M.  D. 
Arlington,    Ky.  Ex.    Pres't  So.   Western  K.  Y.  Med.   Asso. 


L 


ISTBRINB 


Ttie  Standard  Aiitiseptic. 


[STERINE  is  a  non-tOKic,  non-irritating-  and-escharotic  antiseptic,  composed  of  f)Z()ni- 
ferous  essences,  vegetable  antiseptics  and  benzo-boracic  acid.        '• 

[STERINE  is  sufficiently  powerful  to  make  and  maintain  surgical  cleanliness  in  tli. 
antiseptic  and  prophylactic  treatment  and  care  of  all  parts  of  the  human  body. 

[STERINE  has  ever  proven  a  trustworthy  antiseptic  dressing  for  operative  or  acci- 
dental wounds. 

[STERINE  is  invaluable  in  obstetrics  and  gynecology  as  a  general  cleansing,  prophy 
lactic,  or  antiseptic  agent,  and  is  an  effective  remedy  in  the  treatment  of  catar- 
rhal canditions  of  every  locality. 

[STERINE  is  useful  in  the  treatment  of  the  infectious  maladies  which  are  attended  by 
inflammation  of  accessible  surf  aces —as  diphtheria,  scarlet  fever  and  pertussis 

[STERINE  is  especially  applicable  to  the  treatment  of  scarlet  fever,  used  freely  as  ;i 
mouth  wash,  or  hy  means  of  the  spray  apparatus. 

[STERINE  is  extensively  prescribed  in  typhoid  fever  both  for  its  antiseptic  effect  and 
to  improve  the  condition  of  the  stomach  for  the  reception  of  nourishment. 

[STERINE  agreeably  diluted,  is  prescribed  with  very  good  results,  in  the  treatment 
of  diphtheria,  both  as  a  prophylactic  and  curative— internal   antiseptic— agent. 

[STERINE  is  used  extensively  with  good  results  in  the  treatment  of  whooping-cough. 

ISTERINE  diluted  with  water  or  glycerine  speedily  relieves  certain  fermentative  forms 
of  indigestion. 

isterine  is  indispensable  for  the  preservation  of  the  teeth,  and  for  maintaining  the 
mucous  membrane  of  the  mouth  in  a  healthy  condition. 

isterine  employed  in  a  sick-room  by  means  of  a  spray,  or  saturated  cloths  hung  about 
is  actively  ozonifying  and  imparts  an  agreeable  refreshing  odor  to  the  atmosphere. 

isterine  is  of  accurately  determined  and  uniform  antiseptic  power  and  of  positive 
originality. 

isterine  is  kept  in  stock  by  the  leading  dealers  in  drugs  everywhere. 

Lambert's  Lithiatd  Hydrangea. 


Close  clinical  observa- 
tion has  caused  Lain- 
bcrfs  Lithiated  Hyd- 
rangea to  be  regarded 
'  by  Physicians  generally 
as  a  very  valuable  Renal 
Alterative  and  Aiiti 
Lit  hie  A  cent. 


ALBUMIIvURIA, 
BRIGHT'S  DISEASE, 
CYSTITIS, 

DIABETES, 
GOUT, 

HiEMATURIA, 
LITH^MIA, 
NEPHRITIS, 

RHEUMATISM, 

URINARY  CALCULUS, 
and  all  forms  of 

VESICAL  IRRITATION. 


For  Descriptive  Literature,  Address 

.AMBERT  PHARmACALCO.,St.Louis, 


THE  SANITARIUM, 


BATTLE  CREEK, 
MICH. 


%mj:itz^^± 


INCORPORATED  1867. 


■ites. 


gal- 


CHE  largest,  most  thoroughly  equipped  and  one  of  the  most  favorably  located  in  the  Ut  -f  . 
It  is  under  strictly  regular  management.    Eight  physicians,  well-trained  and  of  large  >   .u- 
A  quiet  home-like  place,  where  "trained  nurses,"  "rest-cure,"  "massage,"  "faradizati  .:.■ 
vanization,"  "static  electrization,"  "Swedish  movements,"  "dieting,"  "baths,"  "  phys.  jl  ir,:'i! 
ing,"  and  all  that  pertains  to  modern  rational  medical  treatment  can  be  had  in  perfection  at  r  ;!•?>•..•:  't 
prices.    Special  attention  given  to  the  treatment  of  chronic  disorders  of  the  stomach,  and  disea.  v^  pe  ul-, 
iar  to  women.    A  special  hospital  building  (loo  beds)  for  surgical  cases  with  finest  hospital  facil.Ues  and! 
appliances. 

I,arge  fan  for  winter  and  summer  ventilation.  Absolutely  devoid  of  usual  hospital  odors.  Delight- 
ful surroundings.  I,akeside  resort.  Pleasure  grounds,  steamers,  sailboats,  etc.  Trained  nurses  of 
either  sex  furnished  at  reasonable  rates. 

J.  H.  KELLOGG,  H.  D.,  Supt.,  Battle  Creek,  Mich. 


R 


NTJT-GLTJTEN  BISCtTIT  :  Made  from  the  purest  wheat  gluten  and  nut  meal.  The  only  food  on  the 
market  to-day  that  diabetics  may  eat  of  fieely,  without  danger.  Prescribed  and  endorsed  by  the  physicians 
of  the  Battle  Creek  Sanitarium.  Samples  free  to  physicians  whtn  card  is  enclosed  with  the  request.  Others 
may  have  them  for  two  2c  stamps. 

BATTLE  CREEK  SANITABIT7M  HEALTH  FOOD  CO.,  Battle  Creek.  MicB-