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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. 



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Vol. ii. NO. 1. 



NORTH CAROLINA 

MEDICAL JOURNAL 

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



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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 

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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 
any subscriber tailing to receive his copy promptly, is asked to announce the 
fact to this office. . u- t 

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. 



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 Rep utation, 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^ a nd 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 
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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 
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All communications, either of a literary or business nature, should be 
addressed to, and any remittances by P. O. Order, Draft or Registered Let- 
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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. 



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premium book on Suggestive Therapeutics is only one dollar 
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DESCRIPTIVE LITERATURE 

UPON APPLICATION. 

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One teaspoonful of Celekina 



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A sample bottle will be sent free to any physician who desire- 
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mo CHEMICAL CO., St. Louis, Mo., U. S. A. 



FEVER-KILLER--AIM ANODYNE— AN ANTIPYRETIC 
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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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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. 



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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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Vol. XLI. Wilmington, February 20, 1898. No. 4. 

©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. 

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. 



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. 



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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 th e 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 n il ■lliai H III M IIIMIII U IIIIJIII M IIulril 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 
i fcffections. 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. 

PUBLISHED SEMI-MONTHLY AT ?2.00 PER ANNUM. 

IRobert D. 3ewctt, fID, ^. j£b\tot. 



[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 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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1030 UrALNVT STREET, PHILADELPHIA. 
CtMAlogoe tent on Appltoatfeu. 



NORTH CAROLINA 

MEDICAL J OURNAL. 

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 T Vr R EHT'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 Vita lizing Constituent—P hosphorus: the whole combined in th« form 
of a Syrup with slightly Alkaline Bacteria. 

It Differs in It s 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; i t 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 va lue 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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MEDICAL JOURNAL. 

PUBLISHED SEMI-MONTHLY AT $2.00 PER ANNUM. 

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NORTH CAROLINA 

MEDIC ALJOURNAL. 

A SEMI-MONTHLY JOURNAL OF MEDICINE AND 
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 — P hosphorus; 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 i s largely attributable to its stimulant, tonic, and nutritive 

properties, by means of which the energy of the system is recruited. 
Action is Prom pt; 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 o f 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. 



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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. 

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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- 
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>racing the nerves, it 
trengthens the voice. 



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LISTERINE has ever proven a trustworthy antiseptic dressing- for operative or a< 

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lactic, or antiseptic ag^ent. and is an effective i-emedy in the treatment of cat 

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inflammation of accessible surfaces— as diphtheria, scarlet fever and jjertus.- 
LISTERINE is especially applicable to the treatment of scarlet fever, used freely a 

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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<^ 

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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 

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Listerine is kept in stock by the leading dealers in drugs evei-jwhere. 



Lambert's Lithiatd Hydrangea, 



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by Physicians generally 
as a 7'ery valuable Renal 
Alterative and Aitti 
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ALBUMIISURIA, 
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For Descriptive Literature, Address 

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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 



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NORTH CAROLINA 

MEDICAL JOURNAL. 

S B 

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.