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CONTRIBUTORS TO VOLUME IV

1922

BONNEY. CHARLES W., M.D.
GEYELIN, HENRY R., M.D.
LANDIS, H. R. M., M.D.
LEE, WALTER ESTELL, M.D.
REHFUSS, MARTIN E., M.D.

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PROGRESSIVE MEDICINE

A QUARTERLY DIGEST OF ADVANCES, DISCOVERIES
AND IMPROVEMENTS

IN THE

MEDICAL AND SURGICAL SCIENCES

EDITED BY

HOBART AMORY HARE, M.D., LL.D.

PROFESSOR OF THERAPEUTICS, MATERIA MEDICA AND DIAGNOSIS IN THE JEFFERSON" MEDICAL COLLEGE
PHILADELPHIA; PHYSICIAN TO THE JEFFERSON MEDICAL COLLEGE HOSPITAL! ONE TIME CLINICAL
PROFESSOR OF DISEASES OF CHILDREN IN THE UNIVERSITY OF PENNSYLVANIA;
MEMBER OF THE ASSOCIATION OF AMERICAN PHYSICIANS, ETC.

ASSISTED BY
LEIGHTON F. APPLEMAN, M.D.

INSTRUCTOR IN THERAPEUTICS, JEFFERSON MEDICAL COLLEGE, PHILADELPHIA; OPHTHALMOLOGIST TO THE

FREDERICK DOUGLASS MEMORIAL HOSPITAL AND TO THE BURD SCHOOL; ASSISTANT

SURGEON TO THE WILLS EYE HOSPITAL.

Volume IV. December, 1922

DISEASES OF THE DIGESTIVE TRACT AND ALLIED ORGANS, THE LIVER, PANCREAS

AND PERITONEUM — NEPHRITIS — GENITOURINARY DISEASES— SURGERY

OF THE EXTREMITIES, SHOCK, ANESTHESIA, INFECTIONS, FRACTURES,

DISLOCATIONS AND TUMORS— PRACTICAL THERAPEUTIC

REFERENDUM

LEA & FEBIGER

PHILADELPHIA AND NEW YORK
1922

1922

PRINTED IN U. S. \.

LIST OF CONTRIBUTORS

CHARLES W. BONNEY, M.D.,

Associate in Topographical and Applied Anatomy in the Jefferson Medical
College, Philadelphia.

JOSEPH W. CHARLES, M.D.,

Consulting Ophthalmologist to the Missouri School for the Blind and the
Missouri Baptist Sanitarium, St. Louis, Missouri.

JOHN G. CLARK, M.D.,

Professor of Gynecology in the University of Pennsylvania, Philadelphia.

GEORGE M. COATES, M.D.,

Professor of Otology, University of Pennsylvania, Graduate School of Medi-
cine; Surgeon to the Out-Pa tient Department for Diseases of the Ear,
Throat, and Nose of the Pennsylvania Hospital; Consulting Laryngologist
to the Philadelphia Orphanage and to the Sharon Hospital.

WILLIAM B. COLEY, M.D.,

Professor of Clinical Surgery, Cornell University Medical School; Attending
Surgeon to the General Memorial Hospital for the Treatment of Cancer
and Allied Diseases; Attending Surgeon to the Hospital for Ruptured and
Crippled, New York.

EDWARD P. DAVIS, M.D.,

Professor of Obstetrics in the Jefferson Medical College of Philadelphia.

CHARLES H. FRAZIER, M.D.,

Professor of Clinical Surgery in the University of Pennsylvania; Surgeon to the
University Hospital.

ELMER H. FUNK, M.D.,

Assistant Professor of Medicine in the Jefferson Medical College, Philadelphia;
Medical Director of Department for Diseases of the Chest of the Jefferson
College Hospital; Visiting Physician to the White Haven Sanatorium.

H. RAWLE GEYELIN, M.D.,

Associate in Medicine in the College of Physicians and Surgeons of Columbia
University and Associate Attending Physician to the Presbyterian Hospital,
New York City.

H. R. M. LANDIS, M.D.,

Director of the Clinical and Sociological Departments of the Henry Phipps
Institute of the University of Pennsylvania; Assistant Professor of Medicine
in the University of Pennsylvania; Visiting Physician to the White Haven
Sanatorium.

vi LIST OF CONTRIBUTORS

WALTER ESTELL LEE, M.D.,

Surgeon to the Germantown, Bryn Mawr, and Children's Hospitals; Assistant
Surgeon to the Pennsylvania Hospital; Consulting Surgeon to the Penn-
sylvania State Department of Health; Consulting Surgeon to the Henry
Phipps Institute; Associate Professor of Surgery, Graduate School of Univer-
sity of Pennsylvania.

STAFFORD McLEAN, M.D.,

Assistant Attending Physician to the Babies' Hospital; Attending Pediatrist
to the New York Orthopedic Dispensary and Hospital, and Assistant in
Pediatrics, College of Physicians and Surgeons, Columbia University.

GEORGE P. MULLER, M.D.,

Professor of Surgery in the Graduate School, University of Pennsylvania;
Associate in Surgery in the Medical School, University of Pennsylvania ;
Surgeon to the St. Agnes and Misericordia Hospitals; Consulting Surgeon
to the Chester County Hospital.

O. H. P. PEPPER, M.D.,

Assistant Professor of Medicine, University of Pennsylvania, Philadelphia.

MARTIN E. REHFUSS, M.D.,

Associate in Medicine in the Jefferson Medical College, Philadelphia.

JOHN RUHRAH, M.D.,

Professor of Diseases of Children, University of Maryland and College of
Physicians and Surgeons, School of Medicine.

JAY F. SCHAMBERG, M.D.,

Professor of Dermatology and Syphilology in the Postgraduate School of
the University of Pennsylvania, Philadelphia.

WILLIAM G. SPILLER, M.D.,

Professor of Neurology in the University of Pennsylvania; Clinical Professor
of Nervous Diseases in the Woman's Medical College of Pennsylvania.

ABRAHAM O. WILENSKY, M.D.,

Visiting Surgeon, Beth David Hospital; Adjunct-Attending Surgeon, Mount
Sinai Hospital; Assistant in Surgical Pathology, Mount Sinai Hospital
Pathological Laboratory.

CONTENTS OF VOLUME IV

DISEASES OF THE DIGESTIVE TRACT AND ALLIED ORGANS,

THE LIVER, PANCREAS AND PERITONEUM . . .17

By MARTIN E. REHFUSS, M.D.

NEPHRITIS . . 131

By HENRY R. GEYELIN, M.D.

GENITO-URINARY DISEASES 147

By CHARLES W. BONNE Y, M.D.

SURGERY OF THE EXTREMITIES, SHOCK, ANESTHESIA, INFEC-
TIONS, FRACTURES, DISLOCATIONS AND TUMORS . . 185

By WALTER ESTELL LEE, M.D.

PRACTICAL THERAPEUTIC REFERENDUM . . . .309

By H. R. M. LANDIS, M.D.

INDEX 395

PROGRESSIVE MEDICINE.

DECEMBER, 1922.

DISEASES OF THE DIGESTIVE TRACT AND
ALLIED ORGANS, THE LIVER, PANCREAS
AND PERITONEUM.

By MARTIN E. REHFUSS, M.D.

The literature on the subject of gastroenterology has markedly
increased within the last year, making it difficult in a contribution of
this size to do justice to the many advances which have been recorded
throughout the world. The reviewer finds it difficult to do justice to the
large number of contributions which have appeared on a variety of
subjects, all more or less allied with the digestive tract. In fact there
has been a revival of interest and also a marked increase in the number
of contributions which are investigative in character. It is difficult,
for instance, and undesirable, to discuss all the contributions on the
question of the etiology or the treatment of ulcer of the stomach, unless
these contributions have some special point or merit which would
recommend them. When possible, the reviewer has personally examined
all articles in French, German and English, and has depended on the
excellent abstracts of the Journal of the American Medical Association,
the extracts in the French Archive des Maladies de Vappariel Digestif, as
well as the excellent summary which the American Institute of Medicine
has recently presented. He has, on a number of occasions, investigated
these abstracts and satisfied himself that they were accurate and
representative.

It is to be noted that the roentgen ray has assumed a point of cardinal
importance in all gastro-intestinal investigation, and the number of
papers dealing with roentgen-ray diagnosis has been so great that it is
manifestly impossible for any well trained internist in this line to ignore
them. He thought fit, therefore, to include those papers which were of
sufficient importance. It is also noteworthy that there is a renewed
interest and also a general feeling that the gastro-enterologist must at
least be an internist, and, secondly, a gastro-enterologist. In fact,
there are few divisions of medicine which are as intimately linked up
with the whole system as is the digestive tract.

Contributions on intestinal infections are constantly appearing,

18 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

Bacillus acidophilus has formed the subject of a number of communica-
tions with regard to the treatment of various intestinal infections and
intestinal stasis.

Fractional analysis and also biliary drainage have both received
criticism and approbation, and the time-honored methods of medical
investigation of the digestive tract have established themselves more
thoroughly and completely. In fact, it is realized that as years go by a
tendency is manifested toward the simplification of methods and toward
a routine method of examination. This includes, in the best institutions,
history, physical examination, roentgen-ray examination, gastric analysis
and duodenal analysis, examination of the movement and urine, and
whatever specific tests are necessary for the complete exposition of the
case. We feel that a study of these pages will amply demonstrate the
general trend of modern gastroenterology.

Interpretation of Digestive Symptomatology. Gaither1 reviews the
question of the symptomatology of gastro-intestinal diseases. Discuss-
ing ulcer, he points out the typical history of this condition. On
the other hand, stress is laid on the atypical phenomena attendant on
ulcer. Mention is made of the many factors which might markedly
alter the syndrome. The nature of the lesion, its position and extent,
the possibility of adhesion formation, pyloritis, perigastritis, and even
malignancy alter the clinical course of the disease. Anyone who sees
much of ulcer realizes how frequently an atypical course in the symp-
toms is met with. No mention is made of one of the most frequent
associations altering its clinical manifestations, and that is the associa-
tion with organic disease elsewhere, as well as the associated functional
derangements which occur.

Regarding perforation and hemorrhage it is stated that these occur-
rences, according to Moynihan and Bolton, are the only signs of acute
ulcer. While these symptoms may be the only manifestations of acute
ulceration, there are many of us who believe that all chronic ulcers, or
at least the majority, begin with acute ulceration which may evolve
with nothing but the typically recurring painful indigestion so charac-
teristic of the ulcer type.

Regarding gall-bladder symptomatology, again the underlying con-
sideration is the nature and extent of the lesion. Is the lesion limited to
gall-bladder walls? Is the lesion adherent to the liver, duodenum,
pylorus, hepatic flexure, and the appendix? Is the lesion a simple
catarrh, an active spreading inflammation, or even a beginning gan-
grenous process? The possibility of perforation into the duodenum,
and even malignancy, must also be borne in mind. Mention is made
of the cardiac symptomatology associated with gall-bladder disease,
such as anginoid manifestations and even myocarditis. The reviewer
is of the opinion that most of the cardiac manifestations are vagal in
origin. Secondary pancreatic involvement from gall-bladder disease,
the association of severe infections of the urinary tract secondary to gall-
bladder infections, and the possibility of a secondary arthritis or even

1 Journal of the American Medical Association, October 29, 1921, No. 18, 77, 1407.

I STERPRETATION OF DIGESTIVE SYMPTOMATOLOGY 19

secondary endocrine involvement from focal infection, must be borne
in mind. The association of appendiceal and gall-bladder disease is
common, giving rise to the question as to which is primary. Further-
more, one or both can markedly interfere with gastric function producing
bizarre symptomatology. The point is well taken that when these
phenomena refuse to yield to medical treatment, the possibility of under-
lying organic disease is likely.

In the consideration of appendiceal disease, it must be recalled that
this organ may be attached to the gall-bladder, intestine, ureter, tubes,
ovary, rectum or bladder. The associated or reflex gastric changes, and
even spasm of the colon with high retention, dilatation and ultimate
atony of the cecum, and even colitis must be borne in mind. The writer
stresses the value of involuntary muscular spasm as a hint of underlying
organic pathology.

Pancreatic conditions are a little bit more obscure, although carcinoma
with cachexia is more evident, and, when the head of the pancreas is
involved, jaundice may be an early symptom. These cases may be
(and here the author quotes Garrod) associated with tremor, dermato-
graphia, Moebius' and Stellwag's signs, and even exophthalmos, which
are due to a disturbance of the sympathetic ganglia which lies so near the
pancreas. Regarding chronic conditions of the large and small bowel;
these organs may be adherent to almost any organ in the abdomen and
may present functional, structural reflex changes, spasticity, hyper-
trophy, atony, dilatation and colitis. Malignancy, syphilis, and tuber-
culosis must be kept in mind.

Extrinsic factors inducing digestive disturbances are many; pulmonary
tuberculosis, failing cardiac decompensation, thyroid and other endocrine
disturbances, syphilitic and parasyphilitic affections, reflex conditions
from the genito-urinary tract, etc. This paper is helpful and suggests
in a general way the attitude to be taken toward the analysis of gastro-
intestinal symptoms.

Forman and Roderick review the clinical interpretation of the Wasser-
rnann reaction with special reference to its use in g astro-intestinal cases in a
hospital report. They point out the necessity of knowing how the test is
performed and insist on the importance of knowing: (1) The antigens
used in the particular test. (2) The temperature and time of the pri-
mary incubation. (3) The hemolytic system employed. Blood taken too
soon after a meal yields a chylous serum which will give an unsatisfac-
tory result. Alcohol taken before collection has been known to render
a known positive serum absolutely negative. Serum containing bile yields
a false positive or anticomplimentary reaction. Furthermore, blood
should never be taken after ether or chloroform anesthesia.

The blood should be taken in absolutely clean receptacles and it is
recommended that it be taken either by venous puncture or by the
vacuum tube. It has been found that extracts of normal organs are
better than the extract of the liver of a syphilitic fetus. While the
plain alcoholic extract and the acetone insoluble fraction have proved
reliable, the cholesterinized antigen is by far the most sensitive.
Regarding the manner of incubation, these observers regard sixteen

20 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

to eighteen hours incubation in an ice box at 8 to 10 degrees as preferable
to the incubator at 37 degrees. With the cold method, 16 per cent more
positives are obtained with known luetic sera.

In every case of suspicious nature where there is a positive suspicion
of syphilis and the blood reaction is negative, particularly when the
central nervous system is suspected, it is desirable to test the spinal
fluid.

While syphilis of the esophagus is rare, nevertheless every lesion of
an organic nature should suggest the use of the roentgen ray and a
systematic Wassermann reaction. With regard to the stomach, Mills
regarded 1 per cent of all organic lesions of the stomach as luetic. Four
types of gastric syphilis occur: (1) Simple syphilitic gastritis; (2)
syphilitic ulcer; (3) syphilitic gumma and tumor formation; (4) syphilitic
stenosis of the pylorus. The typical symptoms of gastric syphilis
according to Eusterman are usually a patient in third decade, with
marked and progressive gastric disturbances, but with cachexia, a palp-
able mass (?); anorexia invariably absent, in the presence of a gastric
analysis resembling cancer and with more or less characteristic roentgen-
ray findings. These are given by Carman as follows:

1 . Filling defect.

2. Hour-glass stomach (this is the second most frequent cause of hour-
glass stomach — next to ulcer and more frequent than cancer).

3. Six-hour barium retention in only 20 per cent.

4. Gastric capacity diminished.

5. Stiffening of the stomach wall.

6. Absence of peristalsis in the affected area.

7. Pylorus free rather than obstructed.

8. Patient under the cancer age and not ill in proportion to the extent
of the lesion shown under the roentgen ray.

9. Absence of nische, accessory pocket, or typical incisura.

In those cases of syphilis in which there are gastric complaints and the
cause is not due to the stomach, it may be due to syphilis of adjoining
organs, such as the liver, pancreas, lymph nodes; to perigastric adhesions
of luetic origin ; to reflexes from syphilitic lesions at more distal points
in the abdomen; to toxemia with the cachexia of the disease; and to
specific lesions of the brain and cord.

Syphilis likewise produces organic lesions of the bowel. Syphilitic
ulcers have been described in the duodenum, ileum and colon, and in
all these cases a routine Wassermann should be performed. The
question of luetic diarrhea is likewise one to be borne in mind.

Syphilis of the colon is said to occur with the same degree of frequency
as gastric lues and almost always appears in the distal colon, the pelvic
colon or the rectum.

In the discussion of the acute abdomen, Forman1 is of the opinion that
in all cases of acute abdomen, the case should be considered surgical
until it is proven medical. This rule will result in far less danger than
the determination to make a fine diagnosis while the individual may be

1 Journal of the Medical Society of New Jersey, April 1, 1922, 19, 98.

STUDY ON THE VALVE OF VARIOUS PROCEDURES 21

progressing to a point where the good effects of surgery cannot be
realized. In children, especially, the difficulties in diagnosis are
apparent, and abdominal pain can occur in the absence of all organic
pathology. Furthermore, it may be induced by many conditions which
are purely medical. The abdominal pain of pneumonia in children is
particularly difficult to distinguish from appendicitis. Acute gastritis
is recognized by the history, generalized pain through the upper abdomen,
vomiting of mucus and even blood, as well as the diffuse soreness. Acute
dilatation of the stomach is recognized by the profuse and persistent
vomiting, the upper abdominal distension, and its association with post-
operative complications, as well as its occurrence in certain acute
infections. Acute intestinal obstruction with rapid and diffuse swelling
of the abdomen, absolute constipation and vomiting, is likewise a danger-
ous condition. Ulcers of the gastro-intestinal tract are all primarily
medical, unless complications, such as hemorrhage or perforation as
well as organic obstruction, demand surgery. Acute gastro-enteritis is
medical, while acute diverticulitis is surgical. The great triad of surgical
abdominal conditions (often masquerading under the banner of one
another and frequently defying the best attempts at diagnosis) are peptic
ulcer, cholecystitis and appendicitis. Gastric tabes must always be
borne in mind in the diagnosis of severe abdominal pain, and pyelitis
must be remembered as a cause of unexplained fever.

Study on the Value of Various Procedures for the Determination of Occult
Blood in the Digestive Tract, Together with Some New Methods. In 191.3,
Halley discussed the value of the various methods for determining occult
blood, and was of the opinion that the Adler (benzidine), Meyer (phenol-
phthalein), and Weber (guaiac) tests were the most accurate. Pron1
was of the opinion that the benzidine test was too sensitive, and pre-
ferred the Meyer phenolphthalein reaction. Since then, modifications
have been suggested which occasioned this paper. The need is not for
a test so sensitive that it leads to misleading results. A rough and
hardened feces passing over a normal mucous membrane might produce
a positive result; and with extremely delicate tests bile pigments, derived
from hematin, might, in their normal concentration, induce a positive
reaction. Gregersen pointed out, in 1919, that the feces of normal
individuals could give a positive reaction with tests which were sensitive
to 1 : 3000. Adler, therefore, is of the opinion that a test, to be of value,
should have a delicacy below 1 : 500 and 1 : 1000, showing a minimum
quantity of 0.10 eg. of blood to 100 grams of feces. This theory, how-
ever, has its faults, inasmuch as bleeding is not a continuous process and
is imperfectly mixed with the gastric contents or feces which we wish to
examine. It is, therefore, frequently desirable to have tests of greater
delicacy. Again, outside of the bile pigments, many foods other than
meats, and even certain medicaments, according to this author, can give
a positive reaction.

In discussing the technic employed, emphasis is laid on the necessity
of absolute cleanliness; the necessity of examining the center and not the

1 Archiv des Mai. de l'app. Dig. et de la Nutrition; Paris, 1922, No. 3, 12, 204.

22 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

periphery of the stool ; the necessity of avoiding not only meats but even
insufficiently cooked vegetables and cereals which might, by their
passage, induce abrasion of the intestinal walls. Furthermore, every
other possible source of hemorrhage, such as the nose, throat, gums and
lungs must be ruled out.

The chemical methods are dependent on the principle that an easily
oxidizable body, such as guaiac or benzidine, takes on a special color
from the oxygen of peroxide of hydrogen through the intermediary of
certain oxidases of the blood.

Pyramidon Reaction. This is the test described by Thevenson and
Roland. To the liquid suspected add an equal volume of a 5 per cent
alcoholic solution of pyramidon, then 6 to 7 drops of acetic acid (33 per
cent) and 5 to 6 drops of hydrogen peroxide. The presence of a violet
mauve color is an indication of blood. This test is not delicate, and
small quantities of blood take a long time to register any color.

The phenolphthcdein reaction has two serious drawbacks. In the first
place it is unstable, and in the second place it is too delicate. In fact,
it registers coloration with bile pigment, and, according to Triboulet,
there is a pigment intermediate between hemoglobin and the normal
bilirubin which registers a reaction.

The reaction of thymolphthalein has been placed along with the
phenolphthalein reaction. Gregersen says it has the same sensibility
as the latter; Kiittner and Gutmann claim it is inferior; Boas, on the
contrary, claims excellent results with it.

The aloin reaction, due to Schaer-Rossel, is performed as follows:
To 5 cc of ether acetic extract of feces add 10 drops of peroxide of hydro-
gen and 30 drops of old oxidized turpentine; then add 10 to 20 drops of
a fresh alcoholic solution of aloin, which is yellow in color. An orange
cherry -red color is a positive reaction. While it is not influenced by a
vegetarian diet, there are many other substances which reduce it.

The benzidine reaction, according to most authors, is too delicate; and
Halley claims it is not only sensitive to iron, but it gives a reaction with
salts of iron, potassium iodide, potassium bromide, sodium bicarbonate,
lime water, magnesium sulphate, as well as pus, saliva, muco-purulent
expectoration, and even intestinal mucus and, finally, uncooked vege-
tables with chlorophyl. With dogs, for instance, the ingestion of even
less than 0.5 cc of blood produces a positive reaction. Halley found a
positive reaction with diluted blood to 1 : 225,000, and Oethinger and
Girault to 1 : 250,000. Adler claimed a positive reaction in infant stools
even when no gastro-intestinal lesion existed. Pron, however, is of the
opinion that if the benzidine be made up fresh with acetic acid, and in
dilute rather than concentrated solution, it is of great value.

Gregersen, realizing the defects of the ordinary test with benzidine,
attempted to correct them. He found that the sensibilitity of the
benzidine reaction was dependent on its concentration. In 0.5 per cent
the reaction is sensitive to 1 : 500, and instead of pure acetic acid he
uses one-half strength. Instead of hydrogen peroxide he uses barium
peroxide which is more stable. To 5 cc of the acetic acid (50 per cent)
he adds 0.025 m. grams of benzidine and 0.10 grams of barium peroxide,

STUDY ON THE VALUE OF VARIOUS PROCEDURES 23

and this mixture is then filtered. Gregersen claims that he judges the
quantity of blood from the shade of color, which varies from gray-blue
to deep-blue.

Adler tested the sensibility of benzidine with a solution ot hydro-
chloride of hematin. Benzidine at 0.5 per cent shows a sensitiveness of
1 : 100.000, at 10 per cent, 1 : 500,000; then on adding to normal feces
a solution of hematin the 50 per cent benzidine gave a sensibility of

1 : 500. .

Pron claims the method of Wohlgemuth is, without exception, the
simplest and the most practical. The reaction is composed of two
solutions:

1. Benzidine, pure ?n50 gm*

50 per cent acetic acid 5U cc-

Prepare cold and preserve in brown bottle.

2. Glucose ^ gm<

Ortizon (Bayer) ■* & m-

50 per cent alcohol 5U cc.

Dissolve the glucose in alcohol, heat gently, after cooling add ortizon
and agitate gently; there is always a small amount of residue. In
fifteen minutes filter into a brown bottle. On testing, add 1 cc solu-
tion No. 1 with 1 cc of solution No. 2. This mixture remains good for
several hours. With a pipette apply 1 to 2 drops to fecal smears, but do
not mix. Depending on the blood content, a more or less blue color
appears. The guaiac test is not supposed to be delicate enough.

The method of Kiittner and Gutman of employing a complicated
acetone, acetic acid, sodium chloride solution and guaiac is too com-
plicated for clinical routine.

Koopman regards the chloral-alcohol-guaiac procedure of Boas as the
method of choice. Boas replaces the ether by alcohol and proposes the
following reagent: To 2 cc of a 70 per cent alcoholic solution of chloral,
10 drops of acetic acid are added. Mix in a porcelain dish and let
stand for five minutes, then add a pinch of pulverized guaiac and 20
drops of hydrogen peroxide, or a pinch of barium peroxide; add to fecal
smears.

Other procedures have been recommended: The guaiacol water ot
Levy, necessitating several hours in preparation; the long and delicate
determination of iron in the stool, the paraphenylenediamine of Boas,
the solution of which does not keep; and finally, the leucomalachite; the
rhodamine B (Fuld) ; or the fluorescein reaction which is sensible to the
millionth part, and gives a positive reaction with most organic liquids
both normal and pathologic are methods which have been suggested.

The microscopic determination of hemin crystals is specific but not
delicate. It requires 20 cc of blood, ingested, to give a constant positive
reaction, and with 10 cc three negatives out of five were obtained
(Halley). Finally, the spectroscope offers characteristic bands for
hematin.

The author comes to the conclusion that in ordinary practice only

24 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

the chemical methods are practical. He believes the phenolphthalein
and guaiac tests should be rejected, as well as the original benzidine
reaction of Adler, and also the pyramidon reaction. The Boas chloral-
alcohol-guaiac is the best, and the modified benzidine merits equal
confidence.

The microscopic demonstration of Teichmann crystals lacks delicacy
but is specific; and finally, from the standpoint of specificity and sensi-
bility, the spectroscopic method of Shaffer (hemochromogen) is the one
giving the greatest guarantee. This paper is discussed in detail because
the determination of occult blood is one of the most important in the
armamentarium of the gastro-enterologist, and up until recently one of
the most unsatisfactory. These abstracts should help considerably to
clear the problem.

The Influence of Pituitary Extract on the Gastro-intestinal Tract and
Blood. Gorke and Deloch1 studied the effect of pituitary extracts on the
gastro-intestinal secretions of human subjects, and for that purpose
they used pituglandol, physotmon and coluitrin. These three new
preparations gave practically the same result On the saliva with 6
patients, there was a decrease in 3 cases, no change in 2 and an increase
in 1 case. In the study on the gastric secretion, an injection of 1 cc
of the extract, of the posterior lobe of the hypophysis was made. Four-
teen examinations of the stomach with the stomach-tube were made
forty-five minutes after the ingestion of a test-breakfast. The injections
of the extract were made ten minutes after the taking of the meal. The
results show an increase in the total volume, a relative decrease in free
hydrochloric acid and pepsin, but with an absolute increase in both free
and total acidity in 8 cases. In 2 cases the total volume was decreased,
and the relative values of acid and pepsin increased No effect was
observed in 3 cases. Roentgen-ray study showed increased "pyloric
tonus" and increased "peristole" function. The duodenal tube
remained two hours in the stomach instead of the usual normal rate of
one-half an hour.

Vagus stimulation, with increased tonus and increased secretion, is
more frequent. The duodenal secretions were studied with the tube and
the contents examined for trypsin, diastase, bile pigments, and the
cholesterol content. In 9 cases there was a reduction in the quantity of
the secretion, with an increase of ferment and cholesterol. Three cases
showed an increase of secretion and ferments. In this group, 9 cases
correspond to stimulation of the sympathetic and 3 to stimulation of the
vagus. Many cases showed increased intestinal peristalsis and colicky
pains in the abdomen, and 3 showed profuse diarrhea.

It will be noted that the action on the stomach was predominatingly
vagal, and on the duodenum predominatingly sympathetic.

Visceroptosis. Normal Incidence. Bryant2 in a preliminary com-
munication, discusses the very important subject of the incidence of
ptosis of the viscera. Burckhardt, writing in 1912, had no difficulty in
collecting some (iOO titles on the subject of ptosis, but, as Bryant points

1 Archiv. f. Verdamingk., February, 1922, 29, 149.

2 Journal of the American Medical Association, October 29, 1921, p. 1400.

VISCEROPTOSIS 25

out, few are of a substantial scientific nature. Smith's study of cecal
position in 1050 infants, and the investigation of Alba, in 1909, on some
1870 males and 1020 females, studied from a clinical point of view, arc
probable the most valuable.

Bryant's studies were based on the total of 290 postmortem cases of
all ages and both sexes. In a general way, the following are the results:
Some degree of visceroptosis was present in 48 per cent of all cases
examined ; about 8 per cent more than half the males, and 8 per cent less
than half the females being normal. An examination of the male cases
showed that one or more viscera presented an extreme degree of ptosis
in 10.1 per cent, the fetal group; in 12.4 per cent of the group below
forty years of age; in 8.2 per cent of the group above forty years of age,
and in 10.4 per cent of the senile group. There is therefore no evidence
to indicate that visceroptosis is a progressive disease in the male.

An examination of the female group shows that one or more viscera
presented an extreme degree of ptosis in 17.1 per cent, the fetal group;
in 20 per cent of the group below forty years of age; in 19.4 per cent of the
group above forty years of age; and in 23.6 per cent of the senile group,
visceroptosis was extreme. There is, therefore, some slight evidence
to indicate that visceroptosis is possibly a progressive condition in the
female.

Regarding the individual viscera, however, the evidence is more
conclusive. In both sexes there is no evidence of visceroptosis in the
fetus with regard to the liver, right or left kidney, stomach or pylorus.
On the other hand, the ileocecal valve, the ascending colon, the hepatic
flexure, the splenic flexure, the descending colon and the sigmoid flexure
all show evidence of low or loose attachments in the fetus of both sexes ;
the ptotic condition being most marked in the male at the ascending
colon with 25 per cent of extreme loose attachment already present,
and in the female at the hepatic flexure with 53.3 per cent of extreme
ptosis already present. Throughout life the percentage of extreme
variations from normal is, with few exceptions, greater at every point
examined in the female than in the male. Thus in the case of the ileo-
cecal valve; extreme ptosis in males below forty was 13.6 per cent, in
females of the same group it was 34.5 per cent. In males above forty,
10.9 per cent of cases examined revealed this condition, while the female
group revealed an incidence of 44.4 per cent. In old age this incidence
becomes even more marked, so that 50 per cent of the senile female group
demonstrate it, while the male senile group reveal it in 17.6 per cent.

Many of the generalized statements which occur in the literature are
certainly open to criticism. For instance, the idea that there is a
necessary connection between ptosis of the right kidney and ptosis of
the hepatic flexure, ascending colon and cecum. Bryant, however,
believes that if there is any relation between the kidneys and the flexures
of the colon, it is an inverse one, since ptosis of the hepatic and splenic
flexures tend to decrease with age in both sexes, while ptosis of both
kidneys very definitely tends to increase with increasing age in both
sexes.

26 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

No. of

Per cent

of frequ.enoj

Pi .>ms.

Ulcer.

Viscera.

Absent.

Present.

Extreme.

Liver

32.8

46.6

20.7

162

Right kidney

55.6

35.2

9.3

Left kidney

51.4

42.9

5.7

277

Stomach

46.9

6.2

Pylorus

53.1

28.4

18.5

282

1. c. valve and cecum

39.7

37.6

22.7

208

Ascending colon

47.6

28.4

24.0

251

Hepatic flexure

38.3

41.0

20.7

219

Splenic flexure

75.3

17.5

7.3

197

Descending colon

67.5

24.9

7.6

196

Sigmoid flexure

59.7

32.1

8.2

Average

52.0

34.1

13.9

Total males, 177.

Total females, 113.

Total

cases, 290.

Total observations, 1966.

Therefore, it is evident that visceroptosis affecting the liver, right and
left kidney, stomach and pylorus, is acquired. Visceroptosis affecting
the large bowel in both sexes is largely congenital or developmental.

It is interesting to note in the discussion of this study that Morrison,
of Boston, who based his observations on fluoroscopic examination,
found the stomach in only 18 per cent to be 1 or 2 inches above the
crest of the ilium ; 45 per cent were at the crest or 1 inch below, and 38
per cent were low in the true pelvis. He considers a line between
the iliac crests as a normal boundary line. In 30 per cent of his 1500
cases, he found cecum anywhere from 2 inches below the iliac crest,
and in the pelvis and even on the left side. This is the experience of the
reviewer. Morrison found 40 per cent of his cases showed incomplete
ileocecal valves.

From these remarks, it is evident that Bryant's material was post-
mortem material, examined under conditions which have little or no
counterpart in our clinical investigations. The postmortem subject is
prone and his organs have lost their resiliency, a very different situation
from the individual examined in the upright position back of the screen.
Nevertheless, these studies are of great value as indicating the "absolute
incidence of ptosis. The reviewer has seen many an empty stomach
which only assumed the position of ptosis after it was filled with the
opaque mixture.

A number of contributions have been made to the ptosis problem,
but the important feature seems to be the fact that function, rather
than form, dominates the problem. One does not infer from this that
form cannot dominate function; in fact, this would be far from the
truth, but the impression seems to be gaining ground that only when
this misplaced organ fails to functionate correctly do symptoms super-
vene.

Coffey1 discusses the phases of the situation which impress him. For
instance, in the study of the evolution of the human species, it is noticed
that among quadrupeds the gastro-intestinal tract is suspended by
peritoneal supports, in the form of definite and free mesenteries. In
the erect posture, man has had provided for support of some of the

1 Journal-Lancet, March 15, 1922, 42, 133.

VISCEROPTOSIS 27

heavy organs of the abdomen by peritoneal fusion. In a large number
of the race this fusion has either failed to take place, or does so in rudi-
mentary fashion, with the result that these defective individuals are
potential ptotics. The characteristic pear-shaped abdomen is so
arranged that the psoas muscles on either side form a shelf where most
of the heavy organs rest, assisted by the fusions which have taken place.
In the absence of these fusions, compensatory postural changes tend to
obliterate the shelves and alter the entire body formation. Further-
more, the walls of the abdomen are strong and relatively inelastic, tend-
ing to hold the organs in proper position and at the same time produce
more or less constant intra-abdominal pressure, which goes far to holding
the organs in proper position. Anything which weakens this wall lessens
support, and a lessening of intra-abdominal and mesenteric fat acts in
the same manner. In fact, the intra-abdominal pressure is regulated
not only by the tension of the walls, but also by the quantity of fat, as
w'ell as the gas and gastro-intestinal contents. Reduction of fats tends
to decrease intra-abdominal pressure, and Nature, in order to restore
equilibrium, tends to produce, gas and conserve liquids in the gastro-
intestinal tract, thereby inducing dilatation and gradual atrophy of
the muscular wralls. Medical treatment, according to this author,
consists of hypernutrition and fattening of the patient (preferably
while at rest in bed) bowel regulation, and, finally, postural exercises
such as those recommended by Goldthwait, Franklin, Martin, and
others. These patients must be impressed with the necessity of keeping
up these precautions for many months.

Poos1 discusses the subject of visceroptosis. Among the symptoms
given are flatulence, constipation, cardiac palpitation (particularly after
meals), heartburn, pain in the abdomen and back, varying degrees of
melancholia, headache, lack of energy, sleepiness through the day and
insomnia at night, inability to think, concentrate or remember, coldness
of the extremities and frequency of micturition.

These are all signs of nerve exhaustion and autonomic imbalance, and
in the opinion of the reviewer can scarcely be held as specific to ptosis,
although they do occur with undue frequency in this affection. Poos
recommends the general measures which we usually employ in this
condition— removal of obvious causes; toning up the viscera and nerves,
for constipation, diet rich in carbohydrates; iron for anemia; sedatives
for nervousness, and psychotherapy. Rest and relaxation are indicated,
and the sinusoidal current applied to the back, below the angle of the
scapulas, is advised.

Parker2 discusses the question of support and postural exercises, and
emphasizes the necessity of wearing a belt or support through the waking
hours, and also points out the value of exercises in bed, which enable the
organs to assume their normal position. The exercises of greatest value
are, naturally, those in w'hich the body is flexed on the pelvis.

Einhorn3 discusses the recognition and treatment of minor ailments
of the digestive tract.

1 Illinois Medical Journal, April, 1922, 41, 254.

2 Australian Medical Journal, March 4, 1922, 1, 237.

3 New York Medical Journal, June 7, 1922, p. 681.

28 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

Briefly, these ailments might be mentioned somewhat as follows:

Acute gastritis ; there is anorexia, retching, sometimes vomiting and
the feeling of fullness and pressure over the stomach.

Acute duodenal catarrh shows sensitiveness in the upper right quad-
rant of the abdomen and frequently jaundice.

Acute cholecystitis, tenderness over the region of the liver and bowel.

Acute hepatitis shows likewise some enlargement of the liver, but this
is more definite and tenderness is more pronounced.

Acute enteritis, cramps throughout the abdomen with nausea and
frequent diarrhea and tenderness to pressure in the lower abdomen.

Acute colitis, tenderness over the large bowel, cramps, constipation,
movements with mucus and often blood.

Acute appendicitis, pain, tenderness and rigidity in the right iliac
fossa (McBurney's point).

In all of these conditions, a rise of temperature may be present.
Mention is made as to the method of treatment in these cases, but the
general inference is that these cases should be given rest and an abstemi-
ous dietary.

The chronic minor ailments of the digestive tract include hyper-
acidity, subacidity, nervous indigestion, nervous regurgitation, nervous
eructations, anorexia, sitophobia, chronic constipation.

Conditions which go on for a long time with a train of symptoms which
do not change in gravity, usually belong to functional disturbances.
Conditions showing changes in the subjective symptoms but persisting
for a long time without materially deteriorating the objective state of the
organs are generally neurosis. Diseases lasting only a few months, but
becoming steadily progressive and altering the appearance of the
individual from that of health to obvious disease, are usually those of
organic type and often malignant. Digestive disturbances persisting
for some times, alternating with periods of freedom from symptoms and
often reappearing in steadily severer form, are often due to benign
organic diseases. In this short paper the author discusses in a general
way the commonly accepted methods of treatment in these conditions.

The roentgen-ray investigation of the digestive tract is now a recognized
procedure which is indispensible to any thorough investigation of dis-
eases of this system. In fact, every well-trained gastro-enterologist
realizes the necessity for a thorough roentgen-ray study of the gastro-
intestinal system. The instruments which are now obtainable are of
such a character as to permit of exact work, although the period of
apprenticeship is one which is somewhat arduous. One cannot consci-
entiously take up this line of work without thorough ground-work and
study, and yet it can be safely said that the fundamental principles of
gastro-intestinal roentgenology have now been laid down. Many of the
questions which troubled observers in past years, such as the position
and form of various organs and the interpretation of shadows, have now
been pretty thoroughly cleared up.

The history of gastro-intestinal roentgenography is redolent with
changes in procedure and also changes in our conception regarding the
interpretation of certain images which were presented in this work.

VISCEROPTOSIS 29

Today it lias been conceded that the correct technic for gastro-intestinal
work is a fluoroscopic examination of the organs under the screen
together with a registration of the image, either serially or singly, by the
conventional film or plate methods.

Holland1 discusses the question of the fluoroscope in diseases of the
abdominal organs. He recognizes the fact that both the roentgen-ray
plate and fluoroscope have their limitations, but is of the opinion that the
ideal arrangement provides for the use of both methods. In a general
way, an interesting summary of these methods is given.

For the internist, for instance, the fluoroscope is certainly an extremely
valuable adjunct to other clinical methods. For the trained fluoro-
scopist, the method is one which cannot be duplicated. The observer
must remain in a dark room for at least ten minutes until his eyes are
thoroughly accommodated. Mention is made of the fact that confine-
ment in a poorly ventilated space, as well as severe eye strain, are
responsible for the headache and often the fatigue which the fluoro-
scopist experiences.

In the examination of the stomach one must make certain of examining
the stomach in every position and also carrying on palpation of the
stomach under the roentgen-ray screen. The hands are properly pro-
tected by lead gloves, so that the organ can be deeply palpated in every
position! In diseases of the duodenum, the fluoroscope is almost an
instrument of precision. Beyond this point the condition of the small
bowel cannot be so readily investigated unless there is adhesion forma-
tion or obstruction to the small intestine. The barium enema is by all
means the most satisfactory means of investigating diseases of the large
intestine.

It is interesting to note that, in Holland's fluoroscopic examinations,
there was a record of 90 per cent correct diagnosis. The value of
fluoroscopic examination is one which is largely due to the experience
of the observer, and every gastro-enterologist ought to be encouraged
either to have his patients fluoroscoped or to actually perform the
examination himself. With the modern Coolidge tube and the simpli-
fication of apparatus at the present day, the technical difficulties are very
considerably lessened. It is therefore of interest to review some of the
contributions regarding roentgen-ray studies on the digestive tract.

Charpy2 discusses a form of barium cake which is agreeable flavored.
The patient is allowed to ingest a sufficient number, two or three of
which usually give a satisfactory image, wdiile five or six taken with a
cup of tea permit the examination of the intestinal tract. These cakes
are considered superior to the usual barium soups and gruels.

Several interesting studies were made regarding gastric function. In
one of these, Nielsen,3 investigated the motility of the stomach during
rest and during movement. He examined, for instance, 20 syphilitic
patients who never had any evidence of gastric disease and gave them
the regular rice-gruel, barium sulphate mixture containing 100 grains

1 New York Medical Record, June 7, 1922, 115, 659.

2 Bull, et mem. soc. de radiol. med. de France, Paris, April, 1922, 10, 98.

3 Ugeskr. f. Laeger, Copenhagen, April 6, 1922, 84, 328.

30 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

of barium sulphate. This author found that the stomachy emptied
more rapidly during movement than during rest. He also pointed out
the fact that in women the stomach empties somewhat more slowly
than men during rest as well as during movement.

Lasch1 made a study of the effect of atropine on gastric motility. His
method was as follows: He first roentgen-rayed the stomach to deter-
mine peristalsis, the condition of the pylorus and the gastric evacuation-
time. Two or three days later he observed the same condition again on
the screen, and then injected atropine intravenously while the patient was
being fluoroscoped in order to be able to judge the effect from the very
beginning. He observed different effects on different days in the same
individual. For instance, the evacuation-time was increased, and this
was most pronounced in the hypertonic and hyperperistaltic stomach.
The tone of the stomach was distinctly decreased in cases of hypertonus.
In studying the question of pain, nothing definite could be demonstrated.
Apparently, true spasm was not influenced by atropine, and the influence
on the pylorus was greater when atony existed. Fugitive stimulation
was noted in several instances, but, in general, it might be stated that
the delay in the emptying of the stomach after atropine was the result
of a decrease in tone and peristalsis rather than an actual increase in the
tone of the sphincter.

Schmidt2 discusses the question of serration of the greater curvature of the
stomach in the roentgen-ray picture. Mention is made of the significance
of this portion of the greater curvature Groedel, in his book, interprets
the serrations of the left lateral contour of the stomach as an arrhythmic
and a superfical wavelike movement but does not define its significance.
Schutz regarded it as a new symptom of ulcer, and discusses serration
as a crenated appearance of the lateral border, with notches of varying
size and depth. Stoccada studied the anatomical specimens of the
stomach particularly with reference to the folds of the mucous membrane
and came to the conclusion that serration is not a sign of ulcer of the
stomach . The present author examined 35 1 surgical cases, 2(52 of which
were cleared up by laparotomy. The roentgen ray with the barium meal
was made, including both fluoroscopic and the making of plates. Thirty-
two of the stomachs were even examined after operation. Of the 351
cases serration was found in 114, and on fluoroscopic examination in G8,
on the plate in 02, in both ways in only 16. Ninety-nine serrated stomachs
were operated upon for ulcer of the stomach. The diagnosis was con-
firmed in 93 out of 101 cases of ulcer. Of these, 45 showed serration, on the
plate in 31 cases, on the screen in 22, in both 5. In these positive cases
the ulcer was on the lesser curvature in 31 cases, in the antrum or near
the pylorus in 14 cases, and 11 cases showed spastic hour-glass stomachs.
The serration first appeared when the stomach began to empty, was
rarely ever seen on the lesser curvature and seemed to be unaffected in
any way by the position of the ulcer. With ulcer of the duodenum,
serration was very similar to that of ulcer of the stomach and had
nothing to do with peristalsis. Serration, however, is much rarer m

i Med. kirn. Wchnschr., April 22, 1922, 1, 840.
2 Arch. f. klin. Chir., March 8, 1922, 119, 225.

DIAGNOSIS AND TREATMENT OF ESOPHAGEAL DIVERTICUL1 31

malignancy than in benign ulcers. In 9 out of 26 eases of gall stones,
confirmed by operation, 9 showed serration. In 43 cases of hernia and
adhesive processes in the abdomen, 33 of which were confirmed by
operation, serration was found in 17 and was in no way different from
that found in ulcer of the stomach. In 44 cases of ptosis and atony,
21 of which were operated on, serration was demonstrated in 5. Finally,
in 37 cases where there was no sign of stomach disease but in which
operation was performed for other causes, there were 8 cases, and in 4
of these serration had been seen.

The author, therefore, believes with Schutze that serration is simply
a sign of increased tonus and that it cannot be regarded as a sign of any
certain gastric disease, but rather as a manifestation of a general increase
in tone.

In the consideration of roentgen-ray examination of the gdstro-mtestinal
tract, Hartung1 discusses the essential features of roentgen-ray examina-
tion, and favors fluoroscopy as a routine procedure— with the recording of
important features by plates. The well-known pictures are mentioned :
Sacculation of the esophageal contour in diverticulum ; the stoppage of
food in cardiospasm with its characteristic deformity; six-hour retention
with exaggerated peristalsis he considers an organic lesion (a rule which
is in keeping with our best knowledge at the present time) ; the nisehe
of chronic ulcer; the filling defect of gastric cancer— are precisely what
we are looking for in every case. The author's statement that acute
superficial erosions may show no roentgen-ray evidence is again in keep-
ing with our knowledge of the subject. Cholelithiasis and cholecystitis
are difficult at times of demonstration. Pancreatic lesions may be
demonstrated by changes in the position, or obstruction of the duodenum,
or a pressure defect in the gastric image. Lane's kink and ileal stasis
may be demonstrated. Finally, stasis of the colon should only be
ascribed to ptosis or functional defects when all organic lesions have
been ruled out. Anomalies and inversions, as well as hernias, can be
shown by the roentgen ray.

Barjou2 discusses the question of roentgen-ray examination of the
esophagus. In his opinion, esophagoscopy and roentgen-ray examina-
tion should supplement one another. He discusses the mechanism of
roentgen-ray examination and suggests that the organ be examined by
liquid, opaque and pasty material, and even capsules containing
bismuth. The finding of compression, foreign bodies, stenosis, diver-
ticulum, spasm or atony may all be made in this way.

True megaesophagus is caused by some congenital malformation; or
spasm, atony or inflammation. Atony is best shown by the swallowing
of the bismuth capsule, which descends in stages like descending a
staircase.

Diagnosis and Treatment of Esophageal Diverticuli. Bensaude, Gre-
goire and Grenaux3 discuss the high, or pharyngeal diverticuli.
Pharyngo-esophageal diverticuli are always located in the posterior

1 Illinois Medical Journal, April, 1922, No. 41, p. 258.

2 Lyon Med., March 10, 1922, 131, 187.

3 Arch. d. mal. de 1. app. digest., Paris, May and June, 1922, No. 3, 12, 145.

32 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

wall of the lower pharynx just above the entrance of the esophagus.
In the beginning the patient may have some difficulty in swallowing,
but the condition develops symptoms producing obstruction, dysphagia,
pain, regurgitation especially when the body is inclined forward, con-
gested face, cervical tumefaction, gurgling, feted breath owing to the fer-
mentation of the contents of the sac, and compression symptoms, such
as dyspnea, neuralgia and changes in the voice. Tumefaction in the neck
can sometimes be emptied by pressure, but the roentgen-ray examina-
tion is the imperative one which may be supplemented by the use of
a sound or catheter. The use of a guiding sound, using silk thread which
is swallowed, and guiding the sound along the throat merits much wider
usage. The authors recommend Bruning's esophagoscope. According
to these authors, the roentgen-ray evidence is much better than that ob-
tained by a sound or a catheter and is rather characteristic. The Bruning
instrument is introduced into the obturator of a Sippy apparatus with
the patient in the sitting position. It should be possible to see both the
openings of the diverticulum and also of the esophagus, and these can
be examined in detail. Medical treatment is never satisfactory, although
it is often demanded. It seeks to keep the pouch empty and to overcome

stenosis.

The patient may take small quantities of food into his mouth and
swallow completely before taking more, or may use various maneuvers,
such as sitting in a certain position, or applying external pressure to the
throat while swallowing. The sound may be used to wash out the sac
and, again, on certain occasions the sound may be used for feeding
purposes.

Operation can be done in one or two stages, although the complete
removal of the diverticulum in the first stage is preferable. The reported
mortality of 16.6 per cent is due to the fact that cases have been included
which date back to the preantiseptic era.

An account is given of the operation for this condition and the technic
described which is used for the removal of the diverticulum. Liquid
feeding is commenced on the third or fourth day. During the first few
days the patient may be fed by an enemata and a solution of glucose.
This paper is illustrated, and shows the operative technic and method of
study, and describes three cases in detail.

Cancer of the Esophagus and Radium Treatment. Hanford1 discusses
the question of the treatment of cancer of the esophagus by means of
radium. This author points out the fact that it is difficult to determine
the dosage and length of exposure of radium owing to the difficulty in
exactly determining the extent of a carcinomatous growth in the esopha-
gus. From the few autopsies which he was able to view, he was safe in
assuming that the diseased area was from one to two inches in extent.
He points out the fact that the dose of radium must be sufficient to
produce a killing action on the diseased cells and not a stimulating one.

Mills and Kimbrough mention five requisites for the proper placement
of radium in the esophagus: (1) A knowledge of the location and

1 Journal of the American Medical Association, January 7, 1922, No. 1, 78, 10.

CANCER OF THE ESOPHAGUS AND RADIUM TREATMENT 33

physical peculiarities of the tumor and the resulting stricture, especially
as to the location, extent and direction of stenosis; (2) a form of effec-
tive and non-traumatizing canalization of the cancerous stricture; (3)
a mechanical means of maintaining the radium in direct contact with
the tumor; (4) a ready means of frequent observation as to the position
of the radium during the period of treatment, and (5) a careful selection
as to its filtration and frequency of treatment, guided by such experience
as we have and the individual particulars of the case.

There are three methods commonly employed to locate the position
of esophageal cancer: (a) Fluoroscope; (b) with esophageal sounds,
and (c) by esophagoscopy. In some instances it is necessary to use all
three methods, although this author is in favor of omitting the esophago-
scope except for obtaining a microscopic specimen. Ordinarily this
author obtains a plate of the lesion and this picture is used for subse-
quent reference in the treatment of the case. The patient is then placed
back of the fluoroscope and an olivary body on the end of a spiral wire
is introduced into the canal. When the olivary, body comes in contact
with the stricture, the position of the spiral wire at the point where it
passes the incisors is marked with a piece of adhesive, and the wire is
removed and measured from this point to the tip of the olivary body.
This method gives a definite distance to work on, when the radium carrier
is sent down. If stenosis is not extreme and will admit of a fairly large-
sized olivary body, very little dilatation of the stricture is required.
This open canal, however, does not exist in the majority of patients
seeking treatment, as the patient usually waits until swallowing is
painful in the extreme, and the fluoroscope will show only a small trickle
of bismuth through the stricture. In these cases of extreme stenosis,
he has had more success with a device popularized by Sippy, which
will enter a stricture through which wTater will trickle. The device is
made of piano wire about 3 feet long. On the end of this wire is
soldered a small cone | inch long and § inch in diameter. From
the tip end of this cone to the shoulder is a hole for the passage of silk
thread. A spiral wire tube fits over the piano wire, but cannot pass
over the end because of the cone. On one end of this spiral wire tube is
a screw that will fit into a series of olivary bodies. The device is used
thus:

"The patient swallows a silk thread (silk twist, letter D). This is
accomplished by incorporating about a foot of thread in a 5-grain capsule
or a piece of soft candy. Twenty-four hours is usually sufficient time for
the thread to pass through the stricture into the stomach and become
anchored in the intestine. The mouth end of the thread is then threaded
through the hole in the cone at the end of the piano wire, and drawn
taut. The piano wire is then passed gently down the string and worked
through the stricture. As a rule, this is easily accomplished. At this
stage, the smallest olivary body is screwed onto the spiral wire tube and
passed over the piano wire, down through the stricture. When this is
done the next larger olivary body is threaded over the piano wire, until
three or four have been threaded on the wire, each one a size larger than
the one preceding. The small ends of the olivary bodies are pointed

REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

down. At this time, three or four olivary bodies, beginning with one
about the size of the last one threaded on the wire, are slid down the wire
with their bases pointed down. The second series diminish in size,
thereby making the greatest circumference in the middle of the complete
set of olivary bodies. When these have all been passed through the
stricture, the piano wire is removed, together with the olivary bodies.
This dilator is very satisfactory as there is no danger of trauma, if it is
manipulated properly. Even after the dilatation, patients will say they
feel much better; but, of course, this is only temporary.

"The maintaining of the radium in contact with the tumor is accom-
plished in various ways by different operators. He prefers the apparatus
shown in the illustration. By its use, the patient is not troubled with
the applicator and is barely conscious of its presence in the canal. After
the applicator has been in position the required number of hours, it is
easily removed by means of the attached strings. When the lesion is

Fig. 1. — A, radium carrier. The radium is in the barrel of this tube; B is a
screw cap with a depression in the top (C) to accept, loosely the tip of the spiral
wire (D); E and E' are double strings of heavy linen thread. (Hanford.)

at the lower end of the esophagus, care must be taken that the carrier
does not work down into the stomach. If this occurs, it can, of course,
be removed, but only with considerable force, and injury of the walls
may result. The objection to wires as the means of retaining the
radium carrier in position is that much discomfort is caused the patient,
and the patient cannot retain the radium as long as is desired. By
using the radium carrier the author has described, it is necessary only to
verify the position of the carrier once with the fluoroscope.

"After the radium carrier is in position, a roentgenogram is taken
which will show clearly the position of the carrier. Six hours after the
carrier has been placed, the patient should be placed behind the fluoro-
scope and given a small amount of fluid bismuth. Observations are
then taken to determine if the carrier is still in the right position.

"This requisite deals with dosage, screening, etc. His dose in treating
cancer of the esophagus is based on empiricism. Without doubt,

CANCER OF THE ESOPHAGUS AND KADI CM TREATMENT 35

our dose would be different in many cases if the diseased esophagus was
laid flat before us, for we would then know the thickness of the diseased
area. We are compelled to select a dose that we have found will do
certain things to tissue that has been under our sight. Therefore,
the author has selected 50 mg. as the dose, and the time of exposure to
each position from eight to ten hours. If we wish to irradiate 3 inches of
the canal, we should start at the lower position, and at the end of eight
hours we should pull the string up 1 inch, and at the end of another eight
hours, we should pull it up another inch and so on. He always hopes
that he has gone deep enough into the surrounding diseased tissue, but
not too deep."

In the author's series of 15 cases, he points to 4 cases which seem as
if they were cures, but in all these cases there was benefit from the first
series of treatment. In fact, the dysphagia is relieved in almost every
instance, and therefore it might be said definitely that the majority of
patients are either benefited or their life is prolonged. Furthermore,
it is pointed out that by means of dilatation and the proper application
of radium, gastrostomy is avoided. It is a significant fact that many
observers in this line believe there is a real future in the use of radium
in this condition.

Heller1 points out the accessory uses of the duodenal tube. He mentions
the many uses of the ordinary gastro-intestinal tube such as the reviewer
has described. In the first place, as a syphon in cases of regurgitant
vomiting; in the second place, as an auxiliary common duct in the
presence of biliary obstruction due to cancer or impaction of stone in the
ampulla. He also speaks of methods of introducing the stomach tube
into stomachs of unwilling or comatose patients, one method being by
threading the tube over a piece of piano wire, introducing the tube and
then withdrawing the wire. Another one is threaded through an ordi-
nary colon tube. He also mentions outlining the stomach after the
introduction of the tube into the stomach. He is in the habit of doing
this after the microscopic and mechanical examinations have been made.
This article is suggestive of many of the uses of the gastro-duodenal tube.

Lim2 discusses the histology of the gastric mucous membrane. His
conclusions are as follows from studies on the cat :

The gastric mucous membrane is principally formed by relatively
small tubular glands which become more complex near the orifices of the
viscus, especially near the pylorus the glands are lined by one or more
kinds of cells of which the following types may be recognized:

1. Surface mucus secreting cells, which include the cells lining the
surface and the gland ducts which lead from it.

2. Mucoid cells, of which there are two closely allied groups; (a) the
cardiac and pyloric cells which form the sole lining of the glands within
about 0.2 mm. and 15 mm. of the esophageal orifices respectively;
(6) the mucoid cells proper which occur in the large intervening region

1 Therapeutic Gazette, July 15, 1922, No. 7, 38, 461.

2 Quarterly Journal of Microscopical Science, June, 1922, 66, P. 2, 187.

36 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

(fundus) where they are intermingled with the peptic and oxyntic cells;
they generally occupy the superficial or upper part of the gland-tube.

3. Peptic cells, which are found often in conjunction with mucoid cells
within the deep part of the gland; but formerly both peptic and mucoid
cells were described as chief or central cells.

4. Oxyntic cells, which chiefly occupy the upper portion of the gland,
where they are found between mucoid cells; in the deeper portion of the
gland they take up a parietal position.

The interglandular tissue contains basophil connective-tissue cells,
oxyphil leukocytes, and a few cells with large eosinophilic granules.

The Influence of Cerebral Activity on the Secretion of the Gastric Juice
in Man. Schrottenbach1 describes the result of an interesting series of
experiments carried out on two patients under presumably very exact
conditions. These patients were a girl aged five years, and a man aged
fifty-nine years, in whom a gastric fistula was made to relieve a com-
plete stricture of the esophagus. On these two patients a series of
experiments were carried out, with the idea of studying the effect of
various forms of cerebral activity on the gastric secretion. In other
words, most of these experiments, psychic in nature, are in a way similar
to experiments performed both on animals and on man. In fact, within
recent years, both in England, Germany and on this side of the water,
renewed attention has been paid to the so-called psychic secretion.
This author carried out a series of experiments which might be classified
as follows:

According to the nature of the stimuli; physiologic stimuli, those
for instance which are associated with contact with the mucous mem-
brane of the mouth; optic stimuli; which are due to the sight of food;
acoustic stimuli, or what is known as acoustic associated stimuli, the
idea being that the stimulous to the ears will be one which will effect the
gastric secretion; disagreeable as well as pleasurable emotions; the
effect of sleep or sleepiness; and, finally, of tension.

In a few words, the results might be summarized as follows: The
gastric secretion is increased by the chewing of food, by the suggestion
of food even through so-called optic association or through auditory
association; also by a feeling of hunger and even by pleasurable emotions
which may not necessarily arouse the appetite. This author noted, for
instance, that there was less secretion after optic suggestion than from
physiologic chewing of food, but not infrequently the chewing stimuli
were equalled or even surpassed by the so-called acoustic associated
phenomena.

On the other hand, the secretion is decreased by disagreeable emotions.
The author also mentions the fact that stimuli, for instance, which
increased the secretion may be lessened or even destroyed by a temporary
disagreeable emotion or even by the action of sleep. In other words,
obviously, all these emotions have a great deal to do with the character
and the amount of gastric secretion which is poured into the stomach,

1 Zeitschr. f. d. ges. Neurol, u. Psyclii.it., July 30, 1921, 69, 24.

GASTRIC SYMPTOMS 37

and, furthermore, there is no question hut that disagreeable emotions
and exhaustion can cause a marked reduction in the gastric secret ni;
output.

In this series of studies, an exact estimation was made of the so-called
latent period between the moment of stimulation and the appearance
of secretion. It will be recalled in the experiments which Pavlov and
others carried out that the latent period was occasionally as high as five
minutes between the period of stimulation and the period for the appear-
ance of the secretion. This author, however, found that the highest
period was one hundred and eighteen seconds which is less than two
minutes, while in many instances the latent period was distinctly less
than one minute. For instance, it was interesting to note that the
reception and conduction of optic and acoustic stimuli is much more
rapid than the gustatory and olfactory stimuli.

Gastric Symptoms. An Analysis of 1000 Cases. Blackford1; this
article is a resume of a study of 1000 cases in which the gastric
symptoms were such as to necessitate a gastric examination. In 25
per cent there was no recognizable organic pathologic condition; in 0
per cent he was unable to classify the condition ; in 2 per cent the com-
plaints followed operation; in 35 per cent the intra-abdominal condition
was other than gastric; in 18 per cent the underlying condition was
systemic; and in only 14 per cent was definite gastric disease found.
In a total of 141 gastric lesions the distribution was as follows: Carci-
noma, 38; sarcoma, 1; gastric ulcer, 16; duodenal ulcer, 83; duodenal
diverticulum, 1; gastric syphilis, 1; hair ball, 1.

In the consideration of extragastric causes, the appendix as a reflex
cause was considered only in 78 cases, and the reviewer agrees with the
author that it is wise "to be rather slow in the diagnosis of chronic-
appendicitis as a cause of reflex stomach disorders, unless there is a
definite history of acute attacks and no other pathologic condition is
suspected. In fact, 130 patients already had their appendices removed,
with benefit to only a little over one-half. Cholecystitis, with or
without stones, was the diagnosis in 145 patients; constipation is
presumably the cause in 71 cases, which, if colitis and other conditions
of the large bowel be included, is increased to 98 cases. An interesting
point is the fact that in 3 cases large six-hour gastric residues disappeared
after symptomatic relief of the intestinal condition. Five individuals
with "amoeba histolytica" came in because of gastric indigestion rather
than mild spasmodic diarrhea. Syphilis was the cause in 25 cases;
tabes in 5 cases, and migraine was interpreted as the cause in 16 cases.
Sprue, epilepsy, Addison's disease, goiter, malaria, cirrhosis and metasta-
tic malignancy were found, but too infrequently to classify.

Owing to the conciseness and value of the report I wish to quote
verbatim Blackford's findings regarding "functional" and "postopera-
tive" conditions, as well as his conclusion which must be of interest to
every gastro-enterologist.

1 Journal of the American Medical Association, October 29, 1921, p. 1410.

38 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

Functional Disturbances ob Casks with no Demonstrable
Pathologic Condition. Patients come to the physician's office
complaining of indigestion more often than of any other complaint, yet
in 25 per cent of all such cases we have been unable to demonstrate, or
even seriously to suspect, organic disease accounting for the stomach
complaint. The neurologist may often attach a name to the disease,
and the materialist may say that neurasthenia is as much an organic
disease as carcinoma; yet at present we cannot demonstrate the pathology
and so must class it under malfunction. More knowledge may make this
functional group smaller, but it will probably not be from usually
attributing the symptoms of a hypersecretion or hyperacidity to the
reflex gall-bladder or reflex appendix.

This functional group includes those in whom searching investigation
has failed to show organic disease to account for their stomach symptoms.
We here place that large number showing poor gastric function attribu-
table to irregular hours, over and under eating, chronic dietary indiscre-
tions, visceroptosis, chronic debility, asthenia, neurasthenia, psychosis,
menopause neurosis, etc.

Hyperacidity and hypersecretion, when very marked, are usually of
functional origin. The 5 highest acidities in this series were found in
patients without discoverable abdominal lesion. The 10 patients show-
ing the highest acidities include only 3 with organic disease.

Persistent achylia is unquestionably often functional, but should be
considered so only after ruling out chronic gall-bladder disease, car-
cinoma and chronic colitis. Good gastric function is dependent on
constitutional well-being; hence disturbance of function may be secon-
dary to practically any disease, nervous or organic. The clinician who
fails to spend as much time and effort as is necessary in getting the
whole story leaves himself without the most valuable of all aids for the
correct interpretation of symptoms. Physical examination and labora-
tory findings are important, but after all they give the final diagnosis in
only a small portion of cases.

The asthenic, complaining individual bringing in roentgenograms of
the "fallen stomach" usually attributes all complaints to this cause.
Since the floating kidney went out of style, the reflex appendix is becom-
ing less popular, and the roentgenogram of the stomach more popular.
It seems a pity to inform such a patient of his visceroptosis. If he is so
informed, then more emphasis should be placed on habit and debility
as the cause of the fallen stomach than on the gastroptosis itself. Gastro-
ptosis should be the last recourse as an organic diagnosis, because, after
all, " it makes no difference where the stomach is but how it works."

Functional stomach disturbance may well be divided into two groups,
in the first of which operation has not, and in the second has, been
performed without relief; and the second group is larger than is right.

Postoperative Disturbances. The surgeon often rightly blames
the internist for being too anxious to complete a refined diagnosis on an
"acute abdomen;" the internist may at least as often blame the men
doing surgery for not more carefully eliciting and recording a full pre-
operative history, with complete diagnosis in every chronic complaint.

GASTRIC SYMPTOMS

FINDINGS IN 1000 PATIENTS EXAMINED FOR STOMACH COMPLAINTS.

Previous operal ions

Number

Appen-

Gall-

Present clinical diagnosis

umber.

points.

dix.

bladder.

Stomach.

Pelvi

Organic jiastriir .

141

Carcinoma

Gastric ulcer .

Duodenal divertic-

ulum

Duodenal ulcer

Hair ball .

Gastric syphilis

Sarcoma

Reflex gastric

345

Appendix .

Gall-bladder .

155

Constipation .

3
3

Colitis .

Pelvic .

Tapeworm

Systemic disease

181

Pernicious anemia

Syphilis

Tabes .

Circulatory

Lungs .

Kidneys

Migraine .

Others .

Functional

252

Neurosis

. 156

Hyperacidity .

. 44

Achylia

. 42

Psychic

. 10

Unclassified .

Postoperative

Totals

1000

202

130

Of these 1000 patients, 202 had already had the abdomen opened
before we saw them. Pelvic work had been done on 56 of the 458 women
in this series, and 38 of these 56 we could only call functional com-
plaints. More than half of the patients previously operated on were
diagnosed as having extra-abdominal or no objective pathologic condi-
tion, and yet I do not believe that our profession in the West is particu-
larly derelict in diagnosis or overenthusiastic surgically as compared with
other sections of the country.

One hundred and thirty patients stated that the appendix had been
removed, and it is safe to say that this number would more closely have
approached the total number of abdominal operations if the full facts
could be ascertained. We have tried to establish how often stomach
trouble has been relieved by removal of the appendix, leaving out those
patients known to have had the appendix removed on account of acute
attacks. Somewhat more than one-half of such patients stated that
their symptoms were unchanged by operation. Sufferers from migraine
and from tabes lost the appendix to cure their disease, and 30 patients
lost the same organ for relief of what later proved to be peptic ulcer
or gall-bladder disease; but the large majority of unrelieved patients
were suffering from an indigestion of functional, not organic, origin.

40 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

Careful history would have saved many of these patients unnecessary
operation. (I might add that a few of our own patients operated on
for a ''reflex appendix" still come back to disturb us.) The appendix
is held accountable for stomach disturbance far more frequently than
operative results have justified.

Conclusion. In these 1000 patients:

1. Fourteen per cent actually had organic gastric disease.

2. The roentgenologic examination determined these cases accurately
and with a very small percentage of error. Its negative value is therefore
very high.

3. Thirty-four per cent showed abdominal extragastric disease giving
reflex stomach disturbance.

4. Inflammations of the gall-bladder apparently caused more stomach
disturbance than any. other organic abdominal lesion.

5. Eighteen per cent presented themselves for diagnosis of stomach
trouble which, investigation showed, was due to demonstrable systemic
disease.

6. Twenty-five per cent presented no objective pathologic condition.
Their complaints were considered secondary to habits of living, type of
individual, or to chronic debility.

7. One-third of all cases in which operation was previously performed
fell into the functional group.

8. Six per cent of all cases remained undiagnosed.

9. Thirteen per cent, or more, of patients complaining of chronic
stomach trouble had lost the appendix before coming to the clinic.

10. Ten per cent of all women in this series had had previous pelvic-
operations, one-half done on frankly neurasthenic individuals.

Motor Phenomena Occurring in Normal Stomachs, in the Presence of
Peptic Ulcer and Its Pain as Observed Fluoroscopically. Reynolds and
McClure1 take exception to a statement made by the reviewer in the
Oxford System to the effect that the pylorus did not open with every
antrum or peristaltic contraction.

This series of studies embodies the fluoroscopic observations on the
stomachs of normal individuals and those having duodenal and gastric
ulcer, after feeding a meal consisting of meat and barium. The normal
individuals were studied to obtain data on normal motor activity, while
the observations on individuals with diseased stomachs were observed
to note the motor phenomena associated with the pain intervals.

(The reviewer has fluoroscoped approximately 1000 stomachs a year
for the last five years, always using the barium suspension, and from
his observations on these stomachs, many of which were normal, the
statement that the pylorus relaxes with each peristaltic contraction is
one which he cannot accept.)

There is also a difference in the time interval observed. In the
beginning of the meal the pylorus is much less apt to show regular
relaxation than at a more advanced period, when the gastric contents
have been reduced to a consistency favoring evacuation.

1 Archives Internal Medicine, January, 1922, No. 1, vol. 29.

MOTOR PHENOMENA OCCURRING IN NORMAL STOMACHS 41

(In our opinion there is a marked specificity in pyloric action to
the nature <»f its contents, and this must, in a sense, determine pyloric
action. Reviewer.)

Five types of abnormal motor phenomena were recorded: (1) Exag-
gerated type of normal peristalsis; (2) irregular peristalsis; (3) anti-
peristalsis; I 1) pylorospasm; and (5) the presence of an incisura in the
greater curvature.

1. Exaggerated type of normal peristalsis. This type was observed
with 7 patients with ulceration of the first part of the duodenum. In
1 individual this type changed to the irregular type on the onset of
pain, and in another subject, the change from exaggerated to irregular
peristalsis took place without pain.

2. Irregular peristalsis was observed in 7 patients, characterized by a
marked variation in the time of appearance, duration and depth of the
peristaltic waves. It began with the onset of pain in 5 patients, and after
the onset of pain (either through natural means or after the administra-
tion of sodium bicarbonate) peristalsis became of nearly normal type.

3. In 2 patients there was pylorospasm with demonstrable reverse
peristalsis.

4. Pylorospasm is defined by the authors, judging by its fluoroscopic
picture, as a failure to open its normal width. This phenomenon is
usually intermittent.

:>. Incisura: In 1 cases a small penetrating ulcer occurred on the
outline of the lesser curvature. In 4 patients a small incisura developed
in the greater curvature, coincidently with the onset of pain.

Regarding the phenomena associated with pain, this symptom was
observed in 12 patients with peptic ulcer. In 10 of the 12 its approach
was accompanied by distinct modifications of whatever motor activities
the stomach had previously manifested. If the stomach showed
exaggerated peristalsis and pylorospasm, then the approach of pain was
accompanied by an increase in the depth of the waves, or an exaggeration
of the degree or duration of pylorospasm. If there was irregular peri-
stalsis, then the peristalsis became more irregular or ceased altogether.
If peristalsis had been normal before the pain appeared, then it either
ceased or became irregular after the approach of pain. In 4 cases a small,
but definite, incisura appeared on the greater curvature.

After the cessation of pain, peristalsis became normal or nearly so,
and the stomach rapidly emptied itself, except in 2 cases where exagger-
ated peristalsis with intermittent pylorospasm remained. Mention is
made of the effect of sodium bicarbonate. In 1 case the abnormal
motor phenomena, as well as the incisura, disappeared, while in the
other all pain disappeared ten minutes after the administration of three
grams of sodium bicarbonate — but gastric peristalsis remained unaffected
and the incisura persisted.

This question of the pain, and the motor phenomena associated with
it, has been studied with the balloon and kymograph by Carlson, Hardt,
Hamburger, Homans and others. Carlson and Hardt state that the
pain of ulcers is due to the contractions of the musculature of the
stomach, pylorus, or the first portion of the duodenum. The authors

42 REIIFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

criticize their inferences and term them problematical. Furthermore,
from the studies of Reynolds and McClure, and from the reviewer's
own observations, peristalsis may be active or passive during the
presence of pain. One point is clear, and that is alterations in peristalsis
may be observed by the fluoroscope that are not recorded by the balloon
method.

An interesting observation is recorded in which the pylorus was relaxed
during the pain interval, but in which pylorospasm occurred as soon as
the pain disappeared. Certainly, from the evidence presented in this
paper, and even from those above mentioned, there is no conclusive
evidence to warrant the assumption that pain is purely a motor phe-
nomenon. The authors are of the opinion that there is an alteration of
motor activity in the stomach during pain intervals; but it is nevertheless
true that pain may occur in the absence of peristalsis. We agree with
the authors in the statement, "Our observations do not furnish conclu-
sive proof of the truth of this theory (that gastric and duodenal motor
disturbances are invariably associated with pain) and for this reason,
it must be admitted that the causal relation of motor phenomena to the
pain of peptic ulcer remains problematical."

Bacteriology of the Fasting Stomach and Duodenum: An Experimental
Study Based on Findings in 30 Dogs. Poppens1 points out that this
subject is one of great interest to the clinician, inasmuch as it must be
evident that the intake of bacteria into the stomach is nothing short
of enormous. There is no question that the hydrochloric acid of the
gastric juice is the important factor in combating bacterial activity in
the stomach. A further consideration is the fact that the active factor
is the free hydrochloric acid. Many organisms h^ave the power of
multiplying in the presence of a considerable degree of combined acid.
Miller, many years ago, demonstrated that the number of bacteria in
the stomach decreased as digestion proceeded; Gillespie likewise showed
that there was a marked reduction in the number of bacteria during the
period of digestion.

The author studied the bacteriology of the stomach in dogs. The
animals were kept on a mixed diet of bread and meat for fourteen hours
previous to the operation. With aseptic technic the stomach and bowel
were opened, and some of the contents withdrawn with a sterile pipette.
They were inoculated into dextrose broth, and, after eight to twelve
hours, subcultures were made on blood agar plates, dextrose agar tubes,
plain agar slants, (anaerobic) and litmus milk. The conclusions which
this author reached are as follows :

1 . By taking two to four drops of material from the fasting stomach
and duodenum of dogs a variety of organisms wTere invariably found.

2. Bacillus coli was found much more frequently in the duodenum
than in the stomach (4 times out of 15 in the fasting stomach, 12 times
out of 15 in the fasting duodenum).

3. Non-hemolytic streptococci were rarely found in the stomach or
duodenum (4 times in stomach and 4 times in duodenum, and hemolytic
streptococci not at all).

1 American Journal of the Medical Sciences, February, 1921, 161, 203.

GASTRIC TETANY 43

I. Staplylococei were found in II of 1"> stomachs, and in 3 of 15
duodenums.

These results are important, and emphasize the normal frequency of
organisms capable of playing a pathologic role in the system. It is of
interest to mention some observations made by the reviewer:

In duodenal intubation of healthy adults, in 6 cases only 1 gave sterile
cultures, and 4 gave colon bacilli, and 1 non-hemolytic streptococcus.
Furthermore, while the figures are not available in the large number of
duodenal intubations which we have performed, probably more than
7( ) per cent showed the colon bacillus. It therefore becomes an extremely
difficult task to state whether or not the isolation of bacteria from the
duodenal and the gastric contents is evidence of infection, or whether,
pending our more complete understanding of the bacteriology of these
parts, it is simply a normal incidence. The reviewer considers a culture
evidence of infection when it is accompanied by other evidences of
infection, and also when the cultures are pure, abundant and persistent.
This latter statement is in a sense confusing, but on one point I am
convinced, that in infections cultures are persistent and profuse, while
the non-infected individual shows a varying output. (Reviewer.)

Regarding the duodenum, Lenbuscher showed that the bactericidal
action of the bile and pancreatic secretion was very slight, if present at
all. Gessner, who examined the duodenal contents of 18 persons,
demonstrated a number of organisms.

A New Intestinal Tube, With Remarks On Its Use In a Case of Ulcerative
Colitis. Max Einhorn1 has devised a long, jointed intestinal tube,
somewhat after the fashion of his duodenal tube. It is 15 to 20 feet
long, quite thin, being made of 8 mm. tubing, and consists of "joints"
of about 1 meter each, with metal fittings at each end. The distal
end is a piece of tubing some 20 to 25 cm. in length and about 20 F. in
caliber, containing at its proximal end a stopcock.

A description of a case of ulcerative colitis is given in which the tube
was. passed into the cecum and the patient treated through the tube.
In this way an appendicostomy was avoided and the patient wTas appar-
ently cured. He subsequently passed the tube in the stool, the distal
portion with the stop-cock being first detached.

Gastric Tetany. Carsaet and Augistrou2 discuss a fatal case in which
tetany was associated with a pyloric tumor, and gastroenterostomy was
performed, but the patient did not survive.

Tetany is a serious condition met with occasionally in the course of
gastric disturbances. Robin claims that he saw only 2 cases of gastric
tetany in 10,000 dyspeptics.

The etiology, according to the authors, is usually gastric stasis second-
ary to pyloric stenosis, although Bouveret and Devic, in their memoirs,
say that occasionally tetany is encountered without stasis or hyper-
secretion.

The typical attacks are discussed with tonic convulsion of the hands
and the characteristic "main d 'accoucheur," as the French call it, a

1 American Journal of the Medical Sciences, April, 1921, 161, 546.

2 Jour, de Med. de Bordeaux, January 25, 1922, No. 2, p. 39.

44 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

term as descriptive as any. In other cases, such as the one mentioned,
the thumb is forcibly adducted into the palm and the fingers are tightly
flexed over it, so forcibly as to indent the skin with the nails. The
contractions of the inferior extremities usually follow the manifestations
in the upper extremities, although occasionally they may be alone
affected. It is often possible to induce contractions by pressure on the
nerve trunks or the vessels. This, of course, is the Trousseau sign,
while the Chvostek sign is similar, namely, light percussion over the
nerve induces spasm. Erb demonstrated the galvanic and faradic
hyperexcitability of the muscles contracted.

Bouveret and Devic describe three forms. The first is the one
described above; the second type is more general, involving the neck,
trunk and face, and it is in this latter form that the serious systemic
disturbances become manifest, such as persistent vomiting, dyspnea,
pupillary contraction, weakness in pulse-rate, elevation in temperature,
cerebral troubles, delirium, coma, albuminuria and profuse sweats. A
third form is characterized by a series of tonic and then clonic spasms,
resembling epilepsy.

As to the pathology, many theories have been evolved which we might
enumerate somewhat as follows: Kussmane, who believed it was due
to dehydration of the blood; Miiller found polycythemia; Flexner, and
others, observed contractions of the extremities associated with severe
diarrheas. Certain authors have been able to induce attacks with intra-
venous injections of concentrated salt solution. Fleig, with 30 per cent
hypertonic solution of glucose, demonstrated similar phenomena. So,
too, in certain forms of nervous polyuria, the same nerve excitability
is seen. It has also been reported in the severe diarrheas.

Pylorospasm in Adults: Its Medical and Surgical Treatment. Finney
and Friedenwald's1 article discusses the important point of pylorospasm.
The reviewer can recall several occasions in which distinguished members
of the profession expressed themselves as doubtful of the existence of
pylorospasm. An article such as this is therefore timely, inasmuch as
it attempts to summarize the clinical evidence supporting the syndrome
of pylorospasm, and gives a resume of case histories describing typical
cases.

There is no doubt in the reviewer's mind that pylorospasm is an exceed-
ingly common condition, and that minor degrees of pylorospasm account
for many of the forms of upper abdominal indigestion. Mention is
made of the nerve supply of the pylorus and the role which the autonomic
system plays in its forms. We are now satisfied that the vagus contains
the activator fibers, stimulation of which induces spasm, increased
acidity and increased secretion. On the other hand, the inhibitory
fibers are supplied by the sympathetic system, stimulation of which
inhibits spasm. It is noted that stimulation of the vagus in rabbits
induces pylorospasm, while Rogers has produced, in more thorough
fashion, the same phenomenon in dogs by the injection of certain
extracts of the thyroid, parathyroid and gastric mucosa. Such injec-

1 American Journal of the Medical Sciences, October, 1921, No. 4, 162, 16.

PYLOROSPASM IN ADULTS 45

tion increased both motility and secretion, both of which were inhibited
by the injection of atropine. The same thing can be affected by
the injection of the adrenal extract which stimulates the sympathetic
side. The cause of pylorospasm, according to Rogers, is a continued
failure of the sympathetic side, best relieved by pyloroplasty. Cannon's
researches on the acid control of the pylorus are of course open to con-
siderable criticism. They do not explain the emptying of the stomach
in gastric achylia, the emptying of water, the evidence on the roentgen-
ray screen that material leaves the stomach long before acidity has
reached a grade sufficient to induce the phenomenon, nor do they explain
the evacuation of alkaline meals from the stomach. The suggestion of
Lockhart, Phillips and Carlson that certain motor activities of the
stomach are associated with relaxation of the pylorus, would indicate a
marked association of muscular tonus with pyloric function. McClure
and Reynolds, it will be recalled, were unable to produce contraction of
the splincter by the injection of acid into the duodenum. All this
evidence simply emphasizes the complexity of the pyloric mechanism,
dependent not only on the tonus of the nerve mechanism of the pylorus,
but likewise on the condition on the endocrine regulatory apparatus as
well as the conditions affecting the latter.

These authors divide pylorospasm into the neurotic, irritative and
reflex groups. This classification of course is based on whether the
pylorospasm is associated with a pure neurosis, or with an irritative
condition in the stomach wall itself, or is due to an extragastric lesion,
removal of which results in a disappearance of the spasto. While a
pure spasm of the pylorus can occur as an entity in itself, apart from any
other recognizable provocative factor, nevertheless the majority of
cases are associated with lesions in the stomach or outside the stomach.
Gastric and duodenal ulcer, cancer of the pylorus, enteroptosis, gall-
bladder disease, appendicitis, renal disorders and diseases of the male
and female genito-urinary organs are given as causes. These undoubt-
edly are associated with pylorospasm, particularly gall-bladder and
appendiceal diseases, and one of the worse cases the reviewer has ever
seen was associated with the passage of a renal calculus. On the other
hand, no mention is made of pylorospasm associated with focal infections,
and particularly those in the upper respiratory tract. Some of the
severest types are seen in the hypersecretory crises associated with
duodenal ulcer. The symptoms are given as follows:

1. Mild discomfort and pressure in the epigastrium two to three hours
after meals, and often accompanied by acid eructations and regurgitation.

2. If the spasm is intense, severe pain with vomiting radiating from
the median line into the back is found.

3. At first periodic spasm, later continuous spasm, associated with
food retention.

4. In severe cases vomiting relieves temporarily, precisely as it does
in dilatation of the stomach, and relief can also be obtained by lavage.

5. Vomiting is often explosive in character, resulting in the emission
of a large quantity of acid contents.

0. During the attack physical examination reveals a tender area over

46 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

the pyloric region, and in thin walled individuals the pylorus can often
be palpated as a firm, tender mass.

7. At sometime during the attack hyperacidity can usually be demon-
strated by fractional analysis.

8. Roentgen-ray examination demonstrates the presence of spasm.
In this paper little notice is given to this method, probably the most
accurate and exact for the demonstration of pylorospasm. On the screen
the contracted pylorus, and the inability to manipulate material through
the pylorus, suggest but one thing, namely, pyloric obstruction and
probably spasm. The observer has at his command the use of atropine
or even adrenalin which relaxes functional spasm, but will rarely relax
spasm associated with organic disease of the stomach. Spasm due to
disease of remote organs behaves differently, and those of nervous or
reflex origin usually disappear under the influence of antispasmodics.
Intermittent stagnation and even six-hour retention are findings asso-
ciated with pylorospasm.

The treatment of the condition is naturally treatment of the fault,
change of scene, massage, rest, regulation of the diet and even a well
regulated ulcer cure. During the attacks, morphine and atropine, or,
for pain, codeine with belladonna. Sodium bromide, with chloral, has
its advantages, as well as the use of hot applications to the abdomen,
and thorough lavage of the stomach. Atropine hypodermically may
be used, and Stockton has recommended adrenalin, while Rogers
recommends the administration of adrenalin nucleoprotein. In intrac-
tible cases which have resisted all treatment pyloroplasty is the operation
recommended, and even in gastric ulcer unrelieved by gastroenter-
ostomy this procedure has its place.

Naturally, every case must receive careful medical treatment; failing
in this line of approach, the advisability of pyloroplasty can be con-
sidered.

The Action of Opium on the Stomach. Jarno and Marko1 mention the
divergence of opinion. The general opinion seems to be that opium
increases acidity, tonicity and peristalsis, and also prolongs the gastric
evacuation time. The question regarding the action of opium on the
stomach comes up as to how this mechanism occurs, and what is the
relation between the increased acidity and the delay in evacuation.
The authors studied this from several angles. Fifteen experiments
were performed on the anacid stomachs. Twelve times the evacu-
ation was delayed, twice it was normal, and on a single occasion
it was accelerated. On G occasions tonus was normal, 9 times it
was increased, and peristalsis was always increased. It would seem,
from these experiments on anacid stomachs, that the effect of
opium on the stomach was independent of the gastric acidity. The
alkaloids of opium close the pylorus even in the absence of gastric free
acidity, and the only explanation would be hypertonicity involving the
sphincter. On the other hand, the hyperacidity induced by the drug
would appear to be due far more to the action of the opium on the

1 Wiener klin. Wchnsehr., October 13, 1921, p. 498-499.

GASTRIC AND DUODENAL ULCER 47

pylorus than the effect of the drug on the mucous membrane. The

possibility that the closure of the pylorus prevents the normal alkaline
reflex from the duodenum is of course an explanation.

Gastric and Duodenal Ulcer. Brisotto1 considers the various theories
advanced for ulcer as unsatisfactory and proceeds along the following
lines. He cuts the vagus of a dog and then repeatedly administers
hydrochloric acid by mouth. By disturbing gastric function in this
way and realizing an increase in, gastric acidity, retardation of gastric
motility occurs, a disturbance in the pyloric reflex, and with the induc-
tion ofthese factors ulceration develops. Whether it be angiospasm or
muscular contraction, the association of artificially increased gastric
secretion promotes autodigestion. In other words, a disturbance
of the autonomic system impairs the vitality of the cell elements, with
resulting destruction through irritants, and chronicity is produced by a
more or less permanence in the lessened vitality of these cells. Simple
lesions of the celiac axis, splanchnic nerves, or even the vagus give
uncertain results. The failure of ulcer to follow these lesions is ascribed
to the functional substitution of the intrinsic gastric innervation mechan-
ism, or Openchowski's ganglion. On the other hand, decapsulated
animals develop typical ulcer, and inasmuch as the function of the
autonomic systems is closely linked up to the endocrine glands, and
particularly the suprarenals, it is easy to understand why lesions of these
two systems should produce ulcer.

Panchet2 discusses the diagnosis and treatment of gastric and duodenal
ulcer. Simple ulcer is most common over the anterior portion of the
duodenum or the lesser curvature of the stomach. He believes that
syphilis plays some role in ulcer formation. In the differential diag-
nosis, appendicitis, cholecystitis, enteroptosis, incipient tuberculosis,
renal insufficiency, and cardiac and arterial lesions must be ruled out.
A careful history, with particular reference to pain, vomiting and
hemorrhage, must be made.

The author sees three reasons for operation in ulcer : First, recurrence
of the lesion; second, its tendency to predispose to tuberculosis; and
third, its tendency to malignancy. He considers chronic ulcer not
amenable to medical treatment, but the ordinary case can be submitted
to bed rest, bismuth, milk and rigid hygienic treatment.

For surgical treatment of duodenal ulcer, the methods advocated are:

(1) Gastroenterostomy, with cauterization and suture of ulcer; (2)
duodenectomy, consisting of resection of the duodenal segment; (3)
gastropyloric resection when the patient has marked hyperacidity.
For gastroenterostomy the mortality is 0.5 per cent, and for gastrectomy
3 per cent ; but the cures are 90 to 95 per cent. In 5 per cent of 100 cases
of gastroenterostomy, jejunal ulcer developed owing to high acidity.
This emphasized the necessity of postoperative dietetic care.

For gastric ulcer, the methods are: (1) Simple thermocauterization;

(2) gastroenterostomy best in ulcers near the cardia; (3) gastropylo-
rectomy; (4) Moynihan's Y-gastroenterostomy combined with jejunos-

1 Riforma Medica, Naples, February 6, 1922, 38, 127.

2 Cron. Med. Chir. de la Habana, January, 1922, p. 142.

48 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

tomy. The mortality for thermocauterization is 1 per cent, the cures
60 per cent; and for gastrectomy the mortality is 5 per cent, but
numbers permanent cures greater than all other procedures.

Roentgen-Hay Diagnosis or Gastric Ulcer. Ambrose1 discusses
the roentgen-ray diagnosis of ulcer of the stomach. The technic for
the examination is as follows:

The night before examination the patient is permitted a soft diet,
but no laxative or cathartic is given. The following morning at 5
o'clock the patient is given 4 ounces of barium sulphate mixed thoroughly
in water or buttermilk, and made palatable. The first examination
is five hours later, and the patient is then placed behind the fluoroscope
in the upright position in order to see whether or not there is any barium
still remaining in the stomach, and also how far the barium has proceeded
through the bowel. If there is considerable barium in the stomach
after five hours, it is evidence of gastric retention and is, in the majority
of cases, abnormal. If there is not sufficient barium left in the stomach,
the author gives the patient another mixture of the same ingredients and,
with his gloved hands, proceeds to palpate the lower end of the stomach
and duodenum, first in the antero-posterior direction and then in the
oblique position.

Signs of ulcer consist of a deformation of the duodenal cap, such as
an indentation, nische, and a partial filling defect or an accessory pocket
indicative of perforation.

The next step in the program is to press the shadow upward, putting
the hand on the lower pole of the stomach and pressing upward in such
a way as to determine whether or not there are any filling defects in the
contour of the stomach. If, at this time, any evidence of gastric or
duodenal ulcer is found, the patient is given a hypodermic of -fa of a
grain of atropine, and, after a sufficient length of time, the patient is
reexamined. If the deformities are still present, the assumption is that
the condition is not spastic but is due to some real pathology. At this
point, if necessary, exposures can be made and plates recorded. The
author also makes a mental note of the condition of the heart and lungs,
as well as the esophagus and cardiac end of the stomach when the
patient first drinks the mixture.

Roentgen-ray examination is also used to observe the results of
treatment in ulcer, particularly from the medical standpoint. In the
study of the duodenum, a number of contributions have been made.

Crane2 discusses the question of duodenal deformity in relation to the
symptoms presented and the form of gastric acidity. While it is true
that a deformity of the duodenal cap may be due to other conditions
than ulcer of the duodenum, and while it is equally true that ulcer of
the duodenum may exist in the presence of an apparently intact cap,
nevertheless we are all of the opinion that this form of deformity is the
most characteristic thing in chronic ulcer. This does not rule out the
necessity for making the other examinations. ( Vane has reviewed 1 000
cases with gastric symptoms and discusses, in a general way, the
associated findings.

1 Journal of the Missouri State Medical Association, May, 1922, 19, 212.

2 Journal of Radiology, June, 1922, 3, 218.

GASTRIC AND DUODENAL ULCER 49

Gastric analysis made on 5 to 6 samples taken at fifteen minute
intervals gave four types of curves: 1, the regular half moon form
with the height of the curve in the middle; 2, an ascending type with
the height of the acid curve in the final sample; 3, a descending curve
with the initial high acidity; 4, a sustained curve with a high initial
acidity which is maintained throughout digestion.

Gastric ulcer was diagnosed in 1 26 cases of this series. In 94 of these
the acid curve was plotted, in 49 the curve was of the ascending type,
in 24 of the sustained type, in 16 of the regular type, and in only 5 of the
descending type. In a case of doubtful deformity of the bulb, Crane
would consider the presence of the curve of either Type II or ascending
type, or Type IV or sustained type as pointing to a diagnosis of ulcer.
Of 1000 cases, 413 showed hyperacidity, 119 showed a total absence of
free acid. The diagnosis of duodenal ulcer was made in 126 cases, of
gastric ulcer in 26 cases, and of duodenal cancer in 1 case. Duodenal
ulcer below the bulb occurred on 2 occasions. In only 25 of these 126
cases was an operation performed, although it was advised in many
more, but the great majority of patients showed prompt and satisfactory
recovery under the Sippy treatment. In 4 of the cases coming to opera-
tion, ulcer could not be found. In 1 of these, although there was a
persistent bulb deformity, the history and gastric analysis did not
confirm ulcer; and in another the bulb was normal, but the history, in the
presence of hyperacidity, pointed to ulcer.

Crane is of the opinion that the sound diagnosis of ulcer should rest
on three factors: Ulcer history; the demonstration of hyperacidity;
and the demonstration of bulb deformity. He strictly insists on the
consideration of all the clinical records before the roentgen-ray plates
are examined because they help to reduce the errors in diagnosis.

Carman1 discusses the errors in the roentgen-ray diagnosis of duodenal
ulcer. According to this author, the two most trustworthy indications
of ulcer of the duodenum are the deformity of the duodenal cap and the
combination of retention and hyperperistalsis. In large, but otherwise
normal, stomachs, according to Carman, the frequent causes of error
are spasm from reflex causes, adhesions around the duodenum and
gastric lesion near the pylorus. Duodenal spasm is most frequently
associated with inflammation of the gall-bladder and of the appendix.
On the other hand, gastric lesions near the pylorus may include the
duodenum, and thus make a diagnosis very difficult.

Neoplasms, especially benign and malignant tumors of the duodenum,
as well as duodenal diverticula, are rare. In Carman's series of 522
cases which went to operation with a diagnosis of duodenal ulcer, in
only 23 was ulcer not demonstrated, and in 22 of these there was a
disease of the gall-bladder or appendix, or adhesions around the duo-
denum, or other conditions which required surgery. In only 1 case of
the 522 was nothing found to explain the diagnosis. On the other hand,
of 544 cases in which the diagnosis made was something other than
ulcer, 32 proved on operation to have an ulcer of the duodenum. It

1 Journal of Radiology, May, 1922, 3, 163.
4

50 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

therefore is evident that the percentage of negative errors slightly
exceeds the percentage of positive mistakes.

It might be well to recall, in this instance, that Carman's method of
duodenal study is the administration of a barium suspension, usually
with syrup, and the palpatory maneuver by which the bulb of the
duodenum is filled out to the gastric shadow. This method is by far the
most satisfactory in adequately demonstrating the cap of the duodenum.

Guenaux and Vasselle1 discuss the roentgen-ray diagnosis of ulcer of the
duodenum. These authors examined the patients successively in various
frontal and oblique positions. They claim that while the antero-frontal
position gives one an exact topographic situation of the duodenum, it
frequently leaves much to be desired so far as the appearance of the
whole organ is concerned. The antero-oblique position separates the
gastric and the duodenal shadows. The various parts of the duodenum
then become apparent. The entire length of the bulb can be readily
inspected in the recumbent position. The abdominal position, with
inclination to the right side, is used by these authors so that the bulb
and second portion are seen clearly, and in many instances the passage
of the material into the third and fourth portions may be followed with-
out much difficulty. Furthermore, a series of films are taken to register
the findings in the organ. According to these authors, the direct signs
are those constituted by the deformation of the duodenal image. Diver-
ticular forms are rare and may be sessile or pediculate, the latter form
corresponding to a perforated ulcer, although this picture cannot be
distinguished from a true diverticulum of congenital origin. A small
nick in the bulb is a sign of ulcer in the majority of cases, and in most
instances spasm will exaggerate the deformity. Extensive deformity
of the duodenum may be due either to ulcer internally or to adhesion
formation to the gall-bladder externally. The indirect signs may be
mentioned as hypertonicity of the stomach and not infrequently exag-
geration of the peristaltic contraction of the stomach. According to
some authors, there is abnormally rapid evacuation of the stomach in
some 75 per cent of cases of duodenal ulcer. Furthermore, the question
of the position of a tender spot can be investigated, although too much
dependence must not be placed on this finding. It must be borne in
mind, for instance, that the duodenal and gall-bladder shadows are
frequently superimposed.

Vilvandre2 reports a case in which a nail and a safety pin were swal-
lowed. On roentgen-ray examination the nail was in the second part
of the duodenum. It was later removed by operation and had not
caused perforation.

Hochstetter3 mentions a case of old tuberculous peritonitis which
succeeded in producing stenosis of the duodenum by means of adhesive
bands. The stomach was also embedded in this material.

Quiby4 discusses a case in which roentgen-ray evidence showed an

1 Paris med., April 1, 1922, 12, 284.

2 Arch. Radiol, e. Electropher., London, April, 1922, 26, 249.

3 Fortsch. a. d. geb. d. Roentgen strahlen, April 22, 1922, 29, 17G.

4 Bull, et mem. soc. de radiol. med. de France, March, 1922, 10, 84.

GASTRIC AND DUODENAL ULCER 51

interesting form of duodenum. It was quoted from the case that there
was duodenal stasis due to constriction or adhesive formation, the
diagnosis which was confirmed by operation.

Study of the Early Effects of the Sippy Method of Treating
Peptic Qlcer. Shattuck1 discusses the Sippy treatment as practiced
at the Post-Graduate Hospital, New York, and reviews the effect on 28
cases under observation from six months to two years. Cases were
carefully selected in which typical history and typical roentgenologic
evidence of ulcer were present, and all cases of organic stenoses, hour-
glass stomachs and perigastric adhesions were omitted. After complete
study, history, gastric analysis and roentgen-ray study, patients are
placed under the Sippy treatment, remaining three weeks in bed, getting
up gradually and resuming their normal life after the fourth week.

The following extract is from Shattuck:

"At first, hourly feedings of a milk and cream mixture are given;
later cereals and eggs are added, and still later, other soft, palatable
foods, such as cream soups, custards, jellies and vegetable purees, are
allowed. The diet is further slowly enlarged until, at the end of from
nine to twelve months, it is unrestricted. From the beginning, alkalies
are given hourly in sufficient amounts continuously to neutralize the
free hydrochloric acid. The amount of alkalies required to accomplish
this is determined by testing samples of the gastric contents aspirated
with a duodenal tube, and increasing the amount until further testing
shows that no free hydrochloric acid is present. They are continued
from eight to twelve months. This is the distinctive feature of the
Sippy method. All discovered foci of infection are eradicated, if pos-
sible. In addition, those factors which influence gastric secretion and
motility, such as mental or emotional strain and fatigue states, receive
appropriate attention. Just before leaving the hospital, the gastric
chemistry is again examined; occult bleeding again looked for, and a
second roentgen-ray examination is made. The patients are then fol-
lowed and studied in the same way, for one, two or more years. These
observations are not complete in some of the cases. The periods of
observation vary from six months to two years."

The effects of the treatment might be enumerated as follows:
Twenty-two were duodenal, and (J were gastric, ulcers. Twenty-two
out of 28 remained free from pain since the beginning of their treatment.
Of the remaining (), 1 died, 2 were operated upon, 1 with complete relief
and the other with partial relief. Of the 1 1 patients followed from one
to two years, 9 have remained entirely free from symptoms, 1 is partially
relieved, and the other only partially relieved after an operation.

Regarding the effect on the gastric chemistry. It will be recalled that
Crohn and Reiss studied the results of a restricted diet in 34 cases,
during a period of twro to five weeks. They found that medical treat-
ment reduced the acidity in less than half the cases, but that more than
50 per cent of the patients whose acidities were unaffected, left the
hospital symptom-free. They furthermore showed that 50 per cent

1 Journal of the American Medical Association, October 22, 1921, No. 17, 27, 1311.

52 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

of the patients discharged free from symptoms still retained their
hypersecretion. Of 7 cases which were observed from the standpoint
of gastric chemistry, 3 showed a distinct reduction in gastric acidity and
4 did not.

Ten patients, followed a year or less, were examined for hyper-
secretion by the fractional method. It was present in 6, and reduced
during medical treatment in 2. Two of the 4 patients with persistent
hypersecretion became symptom-free and 2 did not.

Occult blood was present in 6 of 28 cases, and in each instance, under
medical treatment, the occult blood became negative before the end of
the third week and remained negative.

Regarding roentgen-ray studies of healing ulcers, Friedenwald and
Baetjer found little change in the first two weeks, but after prolonged
medication, distinct roentgen-ray evidence of healing. White has seen
the crater or nische along the lesser curvature almost entirely disappear
under medical treatment, and with duodenal ulcer, he found the de-
formity greatly reduced, but rarely completely gone, owing to scar
tissue and adhesions. Favorable changes were noted in the duodenal
deformity in this series, and in 5 out of 6 cases the "nische" and six-
hour retention disappeared under treatment.

Summary. (Shattuck.)

"1. The effects on the symptoms, gastric chemistry, evidences of
occult bleeding and roentgen-ray findings caused by the Sippy treat-
ment were studied in 28 cases of peptic ulcer, 6 gastric and 22 duodenal,
over periods of from six months to two years.

"2. Twenty-two of the 28 patients have remained free of symptoms
throughout the period of observation. Eleven patients were followed
from one to two years with complete relief in 9, and unsatisfactory
results in 2. Of the 17 patients followed for less than a year, 13 have
remained symptom free, and 4 have not.

"3. Of the 17 patients studied with the Ewald test-meal or the
fractional method, 10 showed no marked reduction in acidity, though
all but 2 were rendered free from symptoms. Hypersecretion was
detected in more than half of the cases examined. It was reduced by
treatment in less than half of the cases, though some cases with per-
sistent hypersecretion were made symptom-free.

"4. Six of the 20 patients showed occult blood in the stool. It
disappeared in all cases after three weeks.

"5. In 18 cases, comparative roentgen-ray studies were made from
six months to two years after beginning treatment. Five of 7 patients
with duodenal ulcer, followed from one to two years, showed evidence
of favorable roentgen-ray change; 2 did not. All 6 duodenal cases
followed from six to twelve months showed some favorable roentgen-ray
change. Six cases of ulcer of the lesser curvature of the stomach were
followed. The nische deformity and six-hour residue disappeared during
treatment in 5 of these.

"The purpose of this study is not to advocate the value of medical
treatment in general, nor of the Sippy method in particular. It is
merely to report some of the effects of this method. It is well known

CAST Hie AND DUODENAL ULCER 53

that with all the diagnostic help that has come in the last few years, the
diagnosis of peptic ulcer, even in the hands of the most skilful, is still
subject to error. Apparently, in some cases, nothing short of opening
the stomach or duodenum can settle the question. How large an
element of error there is in this series of cases, I have no way of knowing.
Furthermore, long remissions followed by recurrence of symptoms are so
frequent in peptic ulcer that we should follow the cases for a much
longer period than the average period of observation of this series before
making any final conclusions. However, the effects of the Sippy treat-
ment, even in this comparatively small series, are interesting, and this
method of study should lead eventually to a better understanding of the
value of the various medical and surgical procedures used in treating
peptic ulcer."

Acute Perforation of Gastric and Duodenal Ulcer. Noehren1
gives a number of statistics in this communication which are of interest.
In 59,450 autopsies collected by Bassler, ulcer of the stomach or duo-
denum was found in 4.4 per cent of these 5 per cent perforated. Davis
is authority for the fact that 20 per cent of all duodenal and 7 per cent
of all gastric ulcers perforate. Musser found 28.1 per cent of perfora-
tions in 1800 cases. As to the immediate cause of actual perforation,
the most common is overloading of the stomach, and next to this a pull
or blow on the weakened gastric wall.

In this series of 5 cases of perforation discussed by the author, 1 case
occurred while the patient was eating; another while the patient was
working on the farm; 1 while the patient was working as a carpenter;
and 1 during vomiting caused by the original ulcer. In the fifth case,
however, perforation occurred while the patient was in bed early in the
morning while the stomach was empty, a not infrequent occurrence
according to the literature. In fact, one might say that ulcer of the
stomach or duodenum may perforate at any time. Perforation is more
common in men than in women, and, according to the various cases,
the relative frequency of perforation differs. Farr reports more gastric
than duodenal perforation in 24 cases. Hertz reports 47 gastric and 13
duodenal cases; Petren, 65 gastric and 27 duodenal cases; Struthers
reports only 18 gastric and 72 duodenal cases; Wise, 4 gastric and 5
duodenal cases; Gibbson, 7 gastric and 7 duodenal cases; but all 5 cases
reported by this author were duodenal.

Regarding the possibility of multiple perforation, Eliot collected 26
such cases in all the literature. Regarding the symptoms, the two
most important are pain which is apparent to the patient and rigidity
which is evident to the physician. The pain is sudden and excruciating
in character. It is so severe that the patient immediately gives up what
he has been doing and assumes a strained, immovable position . Further-
more, it is a continuous pain, which enables one to distinguish it from
acute intestinal obstruction and colicy indigestion. It is usually in the
epigastrium, but in many instances travels down the right side toward
the right iliac fossa so as to suggest the possibility of appendicitis. In

1 New York Medical Journal, June 7, 1922, p. 674.

54 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

fact, after peritonitis has intervened, it is practically impossible to
make a diagnosis. In the cases, however, of ulcers away from the
pylorus, leakage may be on the left side. The muscle rigidity is so
pronounced that the abdomen is as hard as a board. Usually, in some
of these cases, it is possible to obtain a previous history of indigestion,
but instances are not lacking in which no such history Avas obtainable.
The author also mentions the fact that vomiting is not a striking symp-
tom, often occurring only once or twice before peritonitis sets in. Dul-
ness in the flanks is a valuable symptom when obtained, but its absence
does not exclude perforation. Absence of liver dulness seldom exists,
according to this author. The absence of any elevation of temperature
or increase in pulse rate during the first year is an important point to
remember. In this series of 5 cases, leukocytic count was made in only
1 case, showing 15,000 leukocytes and 90 per cent polymorphonuclears.
In these cases it is of the utmost importance to make an early diagnosis,
inasmuch as it becomes next to impossible to determine the cause of
peritonitis later on in the progress of the case.

Mention is made as to the method of surgery to be employed, but
here again the important point is an early diagnosis which is the most
important desideratum.

Wiesehammer1 discusses the difficulties in the diagnosis of peptic ulcer.
Moynihan's assertion that more errors are made in the diagnosis of
gastric ulcer than that of any other abdominal disorder is quoted, and
it is pointed out that by far the greatest number of ulcers are duodenal.
Reference is also made to the statement of Graham that duodenal ulcers
have a longer course in years than those of gastric type, and, therefore,
a long ulcer history favors the duodenum as the site of the process.
Furthermore, in duodenal ulcer night-pains are usual, helping to confuse
this condition with cholelithiasis. On the other hand, flatulent disten-
tion of the stomach is more frequent in gastric ulcer and coarse foods are
more likely to produce pain. Regarding the question of hyperacidity
as an exponent or rather as an aid for the diagnosis of ulcer of the
duodenum, reference is made to the statement of Eggleston, that a
number of abdominal disturbances reflexly disturb the function and
chemistry of the stomach causing symptoms which simulate those of
duodenal ulcer. In gastric ulcer, however, the pain occurs usually
earlier in the course of digestion and is usually intensified by a full
meal, but, as Mayo Robson points out, any one, or all of the cardinal
symptoms of ulcer may be lacking. Pain is usually referred to the
epigastrium, but it may radiate in various directions, as a rule to the
left subscapular region. Reference is made to the position of the ulcer,
those near the cardia giving earlier pain, and those near the pylorus
giving pain two and three hours after the ingestion of a meal.

Later in the course of gastric ulcer, complications may arise, including
perforation; adhesion contractions; dilatation of the stomach due
to obstruction; fistulae between the stomach and pylorus with the

1 New York Medical Journal, June 7, 1922, p. 672.

GASTRIC AND DUODENAL ULCER 55

joining organs; local peritonitis ending in adhesions, suppuration or
even abscess; abscess of the liver, pancreas or spleen; pressure on, or
pressure of, the bile ducts, producing jaundice.

Regarding the question of penetrating as contrasted to perforating
ulcer reference is again made to the remark of Eggleston, in which a pene-
trating ulcer is one which burrows through the outside stomach wall
into neighboring organs, such as the liver and spleen. While in a sense
it is a perforating ulcer, it is usually surrounded by adhesions so as to
prevent the serious consequences which, in perforating ulcer, follow the
escape of the gastric and duodenal contents into the abdominal cavity.
The penetrating ulcer is distinguished clinically by greater severity of
pain, greater local tenderness, and the absence of relief after the ingestion
of food and alkalies as is found in the typical simple ulcer.

Perforation is discussed as a symptom of the gravest importance.
Ninety-five per cent of these cases result fatally unless operation is
immediately performed. Very occasionally, in the subacute variety,
medical treatment may be efficacious. Hemorrhage, naturally, is a
distressing complication, but with the march of modern surgery the
dangers of secondary anemia are obviated through the intervention of
transfusion. Although ulcers occur far more frequently on the posterior
wall , perforations are far more common upon the anterior. One observer
asserts that in at least 75 per cent of cases of chronic duodenal ulcer the
patient never consults a physician; while another observer is of the
opinion that 30 per cent of those individuals who obtain relief by the
administration of alkalies really suffer from peptic ulcer. More than
85 per cent, however, are relieved by medical treatment. Often the
only symptoms complained of in ulcer is the sudden, short attack of
epigastric pain, rarely radiating in character, but which may radiate
to the back if posterior perforation is impending. These patients
frequently make a sudden and complete recovery suggesting an erroneous
diagnosis of gall stones.

In another class of cases there are simple, mild, digestive disturbances
ignored both by the physician and the patient, possibly slight gas
formation, slight regurgitation or even vomiting. In a differential
diagnosis between chronic ulcer and gall stones, digestive symptoms
occurring between fifteen and thirty years of age suggest ulcer; later in
life the presence of gall stones is more likely. When, however, attacks
of severe pain follow each other at short intervals and are repeated from
day to day even when acute, the diagnosis must be made with care,
inasmuch as such a condition is more often ulcer with perforation than
gall stones. Likewise, with the occurrence of great pain night after night,
with constant gastric distress, the probable diagnosis is ulcer. Pain that
comes on immediately after taking food and is not relieved by alkalies
suggests the possibility of appendicitis or cholecystitis. In the presence
of symptoms of irregular food distress or pain, anorexia, gas and vomiting
the likelihood of appendicitis should not be forgotten. These con-
siderations simply emphasize the necessity for a very thorough examina-
tion.

56 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

Treatment of Gastric and Duodenal Ulcer. Strachauer1
discusses the question of treatment of peptic ulcer. As is generally
believed, this author is of the opinion that ulcers of the duodenum and
stomach are never exclusively medical nor exclusively surgical. The
treatment depends upon the type, size, and stage of the ulcer. All
uncomplicated, acute ulcers and the majority of ulcers which are
recognized at an early stage should be treated medically; and it is
generally considered that uncomplicated ulcers of the right type respond
promptly to medical treatment. In other words, medical treatment
sorts the ulcers into medical and surgical cases. Furthermore, it
demonstrates whether the diagnosis has been incomplete or incorrect.
The cases designated as incomplete are those having coexisting lesions
in the gall-bladder, appendix, pancreas or other organs. Such com-
plications make the ulcer case a surgical one, and not infrequently a
case diagnosed as ulcer, which fails to be relieved by medical treatment,
turns out to be a lesion of the gall-bladder, appendix, pancreas, liver or
spleen.

In discussing the etiology, the author mentions the fact that the chief
direct cause of ulcer is probably sepsis, a streptococcic hematogenous
infection not infrequently causing infection of the gall-bladder, appendix,
pancreas, kidney and often other lesions.

Regarding the symptomatology of ulcer, the uncomplicated ulcer is
usually demonstrated by its secondary and indirect symptoms, con-
sisting of pyloric spasm, hyperactivity of the pyloric end of the stomach,
and in some cases hyperacidity and hypersecretion. The uncomplicated
ulcer, however, gives no direct symptoms.

Regarding the medical treatment of this condition it is realized that
many ulcers remain quiescent, and that in many instances the so-called
medical cure of ulcer consist of a disappearance of these secondary
symptoms, but true healing of the ulcer and relief of the secondary
symptoms are different conditions. A true cure means a healing or
eradication of the ulcer. Gastroenterostomy relieves pyloric spasm,
ensures more rapid emptying and mechanically drains the results of the
hyperacidity and excessive secretion. Furthermore, the influx of the
duodenal secretions results in a reduction of the acidity, the free 40 to
50 per cent and the combined acidities 30 to 40 per cent.

Regarding the surgical treatment of this condition, we all believe that
pyloric obstruction is the true indication for gastroenterostomy. This
author believes, however, that the excision of the calloused ulcer should
always be combined with gastroenterostomy when this is operatively
feasible. Transverse excision of duodenal ulcer and suturing is the
operation advised. Ulcer of the stomach or duodenum, when associated
with low activity, may at times be appropriately treated by resection or
an operation of the Finney type. Periulcerous edema and inflamma-
tions, as well as close proximity to the common duct or posterior wall,
are contraindications to gastroenterostomy, but with greater experience
in the simple resection of ulcer an increased number of these operations

1 Minnesota Medicine, May, 1922, No. 5, 5, 290.

GASTRIC AND DUODENAL ULCER 57

will be found, according to this author, and a decreasing number of
gastroenterostomies.

The author classifies ulcers as follows:

1. Soft lesion, relatively small, superficial, no deeper than the sub-
mucosal absence of surrounding induration; this runs the benign clinical
course and is usually cured by medical treatment.

2. Large size, deep penetration, frequently perforating; marked
induration, scar tissue, margin of connective tissue and resulting anemia
constitute serious obstacles to healing. Surrounding edema requires
resection or eradication with a cautery.

3. Small ulcer, localized with scar and readily resectible.

4. Duodenitis, as recently described by Judd. Stippling, congestion,
edema, thickening present but no scar; no crater, but multiple small
ulcers present and leukocytic infiltration.

Dietetic and Treatment Regulations in Gastro-duodenal Ulcer. The
following excerpt is by Bassler.1

"The treatment is begun w7ith no food by mouth for twenty-four to
forty-eight hours. During this time the patient is given calomel in
quarter-grain doses every fifteen minutes for eight doses, and Carlsbad
salt twelve hours after finishing and at twTelve-hour intervals during the
fasting period. Cool, but not iced, water is allowed to be drunk in
sufficient quantities to allay thirst. Alkalies are administered from the
beginning to neutralize any gastric juice secretion that may be present.
During the fasting period, 10 grains each of sodium bicarbonate and
bismuth subcarbonate are given every three hours, six doses in all in
twenty-four hours, there being an interval of six hours through the night.

"The feeding is then begun. Three ounces of a mixture of equal
parts of cream and milk are given every hour from 7 a.m. to 7 p.m. for
three days (1835 calories), and the alkaline powders of sodium bicar-
bonate and bismuth subcarbonate. To keep the bowels open, an
alternating powder of sodium bicarbonate and calcined magnesia are
given midway between each feeding. This corresponds to the first
three days' method of Sippy, and represents about 1325 calories a day.
On the evening of the second day of this feeding, note is made if there
is any free acid secretion residual in the stomach. This is done usually
at 1 1 p.m. by aspiration of the stomach contents with a fractional test
tube and testing the return, or by swallowing a gelatine capsule having
an extension of string inclosed in the capsule impregnated with Congo
red or dimethyl and dried and withdrawn after being in the stomach
fifteen minutes. On the finding of a positive acid, the urine is voided
and passed again in an hour, note being made of the reaction of the last
specimen. If no acid is present in the stomach (even if the urine is
slightly so), no alkalies are given throughout the night for the next
fifteen days of the bed treatment. Generally by this time the stomach
is negative to acid and urine also. If acid is met with in the stomach
and urine also, alkalies are given at three-hour intervals throughout the
night for the remainder of the days in bed in quantities to keep the urine

1 New York Medical Journal, June 7, 1922, pp. 670-672.

58 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

alkaline or neutral to litmus paper. Modification here depends upon
the reaction of the urine, this being noted at the end of the day and
before feeding is resumed in the morning.

"On the sixth day from beginning the treatment, a mixture of eggs
cream and milk is given at hourly intervals. Soft eggs and cereals are
not employed as Sippy advises, for the reason that whole eggs, and
especially when they are cooked, cannot be accurately controlled in
quantities. Cooked eggs had better not be given, and no cereals should
be given until after the bed treatment is terminated, for they tend to
diminish the best results. The mixture I employ is the following:

Amounts
at feeding.

Milk.

Cream.

Eggs.

Calories.

Time number.

6 to 9 days
9 to 12 days
2 to 15 days

3£oz.
4 oz.
4IOZ.

25 oz.
22 oz.
20 oz.

25 oz.
34 oz.
44 oz.

2
3
4

2050
2650
3275

Hourly 13
Hourly 13
Hourly 13

"From the fifteenth to the twenty-first day the feedings are in five-
ounce quantities of equal parts of milk and cream. Four eggs in the
day are allowed cooked in any soft wTay. At this time 40 grams of
sugar are allowed, not in the form of saccharose (cane sugar) which
stimulates acidity and tends to constipation, but as lactose, maltose,
etc. The feedings at this time are extended to two-hour intervals, and
the milk and cream mixture on thickly buttered toast at two meals is
allowed. (This represents 3450 calories a day.) Effort is made in these
six days to lengthen the interval of feedings so that on the twenty-first
day meals of milk, cream, eggs, bread and butter and sugar and milk
and cream are given at 8, 12, 4 and 8 o'clock, with one or the other of
the alkaline powders one hour after each of them, and a milk and cream
feeding at 10, 2, 6 and 10 p.m., followed by a powder.

" We must agree with Sippy that the after-treatment of these patients
is most important. I find, though, that the hourly feedings with city
people are not practicable and feedings of milk and cream hourly between
a light breakfast, luncheon and supper, even with the thermos bottle
method he advises, need not be followed. For the first month out of
bed, I do not allow soft or strained foods, such as jellies, marmalades,
vegetables, or leguminous purees as Sippy advises. Instead patients
are kept absolutely on the four foods mentioned above, and a diet
which represents 3780 calories a day is strictly maintained. Such a
diet is given below.

"The diet is a temporary one and is to be continued until a change is
made. The plan is not to partake of any solid foods whatsoever and
to take the foods that are suggested at regular intervals of four hours
during the day, making sure that a strict regularity is preserved and that
the foods are divided up rather evenly in quantity for each time. A
glass of plain fresh milk and perhaps a few crackers should always be
taken between meals and before retiring, and an extra glass of milk
during the night if there is distress in the stomach.

"The diet consists essentially of only four foods, namely, eggs, fresh
milk and cream, well cooked cereals, bread and crackers, and nothing
else in the food or fluid line (excepting plain water) should be taken.

GASTRIC AND DUODENAL ULCER 59

The eggs may be eaten raw or cooked in any form, or may be taken in
the milk. The milk may be warmed if desired, but should not be taken
too hot or too cold. The ten minute modern breakfast foods or any
form of oatmeal should not be eaten, the old fashioned forms of ground
corn, farina, rice, tapioca or sago, well cooked, being the best. The
bread should not be too fresh (one day old), any of the sweetened or
unsweetened crackers can be used, and all forms of simple cake, providing
there are no nuts, raisins, seeds or preserved fruits in it.

"The total amount of food in one day should be: Four eggs, 1 quart
(4 tumblerfuls) of milk, \ pound of fresh unsalted butter, or | pound of
butter and an extra quart of milk, 2 rolls or 4 medium thick slices of
white bread, \ pound of baker's cake or crackers, \ pint of fresh cream,
and \ pound of cereals.

"On this four-meal-a-day plan with the interval feedings, I use 8
powders each taken one hour after a feeding of any kind. During
this first month out of bed the activities of the individual are restricted,
this with the initial bed treatment taking eight weeks.

"After the eighth week the 8, 12, 4 and 8 o'clock meals are diversified
with the following selections, plain milk being taken midway between
meals and the alkaline powders one hour after each feeding: Purees
or creamed soups (barley, rice, peas, beans, celery); gruels (flour,
cracker, barley, Indian meal, farina). Plain crackers, baker's cake,
pound cake, toast, rolls; jellies, rice, tapioca; ground or mashed vege-
tables; puddings, rice, tapioca, bread, cracker; custards, vanilla and
chocolate, blanc mange, whips and souffles; gelatines; plain ice cream;
malt, milk cocoa, cocoa and chocolate.

"This is kept up for four months when the following diet is prescribed
and the powders changed to a combination of the two which were used
before. The following is the combination which is used most frequently :

Magnesia usta

Bismuthi subcarbonatis I aa 15

Sodium bicarbonatis
Sacchari lactis J

Fiat pulv.
Sig: Take a teaspoonful in water after meals.

"The general plan of the diet is to take three moderate sized meals
at regular intervals during the day, and to take supplementary meals
of milk, reenforced with cream, cocoa and crackers between meals and
before retiring. Although food should be taken at least five times
during the day. All of the solid foods should be tender, cut very fine
on the plate and thoroughly masticated before swallowing. Olive oil
may be taken before the main meals in hypersecretion and hypermotility.

"Foods permitted for main meals are: Beef, lamb, and chicken,
roasted or broiled and taken only once a day; fish, any kind and in any
form, other than fried, and taken once a day; cereals (with the exception
of oatmeal and shredded wheat biscuits) well cooked and taken with
cream in the mornings; vegetables, any that are well cooked and mashed
with the exception of green vegetables; tubers, such as baked or well-

CO REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

mashed white potatoes, squash, parsnips and turnips; desserts, any
made of milk, cereals and jellies, no fruits, berries or nuts. Butter,
cream, milk and cereals and eggs still remain the main foods of the
daily diet. If the symptoms become marked again, these should be the
main articles of the diet for a while, when the more general plan may be
followed. The best drink at the meals is Vichy or any alkaline water.

"At the end of six months a normal diet is employed. The following
list of foods that will be especially injurious and must not be eaten is
given to the patient :

"One or two minute cooked breakfast foods; rough vegetables such as
cabbage, sprouts, cauliflower, artichokes, asparagus, beets, celery,
corn, cucumbers, kohlrabe, onions and tomatoes; foods which contain
pits, seeds or skins, or nuts; canned or smoked meats or fish; lobster,
crab, shrimp; cheese of any kind excepting cream cheese; too much
pastry, especially that cooked in molten fat, such as doughnuts and
fritters; foods that are too sweet, such as jams; fruits such as cherries,
cranberries, figs, grapes, musk melons; coffee, strong tea, alcoholic and
malt beverages.

"During the second month roentgen-ray treatments are given to the
stomach, these usually being six in number, given at five-day intervals.
The patient is roentgen-rayed on an empty stomach which contains 2
ounces of bismuth subcarbonate. The exposure at twenty-four-inch
distance is one minute, 5 to 10 milliamperes, five-inch spark gap,
2 millimeters of aluminum and thickness of sole leather used as filters.
Occasionally some form of organic iron is taken by mouth or a
ferruginous preparation by hypodermic injections."

Doegee1 discusses the question of the etiology of gastric ulcer.
In this article he points out the fact that the theory of trauma to the
stomach is susperseded by the teaching of the deleterious effect of
hyperacidity on the stomach wall, and the selective action of bacteria
on the mucous membrane, and lately, of the neurogenetic origin of gastric
ulcer. The fact that gastric ulcer is so frequently associated with many
general conditions as well as localized phenomena throughout the
digestive tract has made Roessle consider chronic gastric ulcer as the
secondary disease, secondary to, and following in the wake of, a variety
of other primary effects. The idea is that this condition follows the
primary one in the sense of being secondary to it and more or less
dependent on it.

The author quotes Hart who claimed that 56 per cent of the 166 cases
which he studied, showed signs of a definite arterial sclerosis. In
Hart's series, there wTas also 23 per cent of peptic ulcers, histories of
which showed that they were effected simultaneously with gall stones.
These instances only became apparent in the older cases, however.
An affection of the central nervous system was present in only 17.4
per cent of 166 cases. The author, in this discussion, also mentions the
theory of bacterial implantation, although he finds he is unable to
accept that theory. The spasmogenic theory of Yanberbman is also

1 Wisconsin Medical Journal, June, 1922, p. 1.

GASTRIC AND DUODENAL ULCER 61

based upon the existence of localized spasm in the submucosa and is
presumably based upon a disharmony in the visceral nervous system.
The author also quotes the findings of Gundelfinger with his experi-
ments on dogs.

This author came to the following conclusions: (1) That neither
vagus irritation nor vagotomy caused organic disease in the stomach or
duodenum of dogs. (2) That the celiac ganglion irritation or extirpa-
tion lead to unquestioned erosion or ulcer formation in 100 per cent of
cases. From this standpoint it would be probably not the vagus, but
the sympathetic, system which is at fault. Rather, more, it would seem
the loss of the celiac ganglion and the consequent absence of the
sympathetic influence of the plexus of Auerbach and Meissner was
responsible.

Cause and Prevention of Gastro-jejunal and Jejunal Ulcer. The
important factors preceding the appearance of gastro-jejunal ulcer
according to Wilensky1 are: (1) An operation of some kind; and (2)
a preexisting gastric or duodenal ulcer. Regarding the operation, every
step in the process is supposed to be associated with a factor which
might be concerned in the formation of ulceration, the position of the
stoma, the use of the clamps, the use of non-absorbable suture material,
marginal necrosis and injury to the tissue; but the wTide diversity of
opinion favors the idea that these are only incidents. Certainly, if
they were causes, the number of gastro-jejunal ulcers would be definitely
increased.

The second important cause, according to this author, is the presence
of preexisting ulceration. We believe, however, that most of the motor
and chemical alterations in the stomach are secondary. At least,
Wilensky does not believe they are primary factors in the production
of this type of ulceration. He believes that in practically every instance
there is a preexisting ulceration. He has never seen this type of ulcera-
tion follow a gastroenterostomy where the operation was performed
in the absence of ulceration or conditions associated with ulcer (car-
cinoma for instance).

This would seem to indicate that the secondary gastro-jejunal ulcers
and the primary gastric ulcer are similar lesions, subject to the same
etiological causes and the same type of development.

Gastroenterostomy. Bonar2 studied the stomach in various con-
ditions before and after the operation for gastroenterostomy. Each
patient was submitted to fractional analysis, a chemical analysis of the
feces, and an roentgen-ray examination of the stomach. Notes were
made before operation, and then the patients were examined six months
after operation by means of the test-meal and the roentgen-ray. After
gastroenterostomy for prepyloric ulcer and the free hydrochloric acid is
lessened, but the total acidity roughly reaches the same level, bile enters
the stomach during the meal and the stomach empties more readily.
Pyloric ulcers have the same type of curve after operation as before
operation ; duodenal ulcer has high acid secretion in the rest period, and

1 New York Medical Journal, June 7, 1922, p. 668.

2 Lancet, November 5, 1921.

62 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

slightly reduced free acidity during the digestive period. The total
reaches the same figures as previous to the operation.

In carcinoma, the total and free acidity are low, both before and after
the operation. In all cases the evacuation is accelerated after operation ;
a varying amount of bile enters the stomach ; and finally, in all cases the
operation relieved pain.

Clendening1 discusses the cause of unfavorable symptoms after
gastroenterostomy based on a study of 36 cases. This author prefers
the term "unfavorable symptoms" rather than failure, because the
symptoms arise from situations dependent on the operation rather than
the recurrence of the original disease. The old idea that because
the food may continue to go through the pylorus; or that it may enter
the jejunum too rapidly; or that a vicious cycle is established, are ideas
which have been largely dissipated through exact and accurate observa-
tion. This author reviews the physiology of the stomach and also the
causes of symptoms. He divides these cases into those in which the
patient has symptoms while still in the hospital (immediate bad results) ;
and those which come on later and more gradually, which may be
classified as remote bad effects. The early symptoms are frequently
postoperative complications, but the causes of the late "unfavorable
symptoms" following gastroenterostomy are: (1) Jejunal ulcer; (2)
recurrence of ulcer, particularly those on the posterior wall and not
infrequently due to lack of proper dietetic regulation ; (3) diarrhea from
too rapid evacuation, or even an enteritis induced by improperly digested
food or bacteria; (4) dilatation of the jejunum from too large a stoma;
(5) gastric stasis from high implantation of the stoma; and (6) super-
imposed gastric disease.

Regarding the Symptoms of Marginal Ulcers Following Gastroenteros-
tomy. Schuldt2 discusses this general subject and particularly pain
after food or without food; pain usually at night; pain of a cramp-like
nature; pain in the epigastrium and to the left of the navel and the left
rib border; vomiting of blood and blood in the stool.

Moreau3 discusses the duodenal reflex after gastroenterostomy, and
claims that the so-called vicious cycle so frequently attendant on this
operation is not so serious, and rarely gives rise to any disturbance.

Rowlands4 in discussing "vicious cycle or regurgitant vomiting after
gastroenterostomy" says that failures are chiefly due to jejunal ulceration
and vicious cycle. This form of regurgitation, according to this author,
who speaks from fifteen years' experience, is due to variable degrees of
intestinal obstruction at, or near, the anatomosis and is usually the
result of faulty technic, or adhesions or contractions developed after
operation. Two clinical types are described; one acute vicious cycle
and the other chronic. The acute form develops in a few days after
operation, and, unless relieved, results fatally. The chronic form
shows vomiting, once or twice every few days or weeks, of large quanti-

1 Journal of the American Medical Association, October 15, 1921.

2 Minnesota Medical, April, 1922, 5, 243.

3 Bull, et Mem. Soc. de Radiologic Med. de France, February, 1922, 10, 44.

4 Guy's Hospital Reports, London, January, 1922, 71, 68.

GASTRIC AND DUODENAL ULCER 63

ties of bile-stained fluid. Acute attacks occur with severe pain and
discomfort, vomiting with loss of considerable fluid, and ensuing thirst.
In acute vicious cycle the diagnosis must rule out anesthesia vomiting;
hemorrhage; paralytic distension; intestinal obstruction (lower down);
and finally, peritonitis. The treatment of vicious cycle is lavage and
operation.

Panchet1 discusses the subject of jejunal ulcer. The frequency of
this condition is given as high as 4 to 5 per cent, and while one cannot
explain the cause, as Wilensky pointed out, any more than one can
truly explain the cause of peptic ulceration, nevertheless this condition
is favored by: (1) Utilization of non-absorbable suture material; (2)
traumatism by clamps or fingers producing erosions and hematomas;
(3) suppuration of the anastomosis by careless suture or trauma; (4)
faulty technic; (5) too rapid normal finding; (6) hyperacidity, and (7)
suture infection from the upper digestive passages, such as bad teeth,
or nose and throat infections.

Symptoms of jejunal ulcer fall into three periods: One a free period
of about eighteen months following the operation; then a period with
digestive manifestations, such as heaviness, distress, uneasiness, eructa-
tions suggesting delays in gastric evacuation; pain and regurgitation
suggestive of hyperacidity; and, finally, such complications as jejuno-
colic fistulas and abscess of the abdominal wall.

Roentgen-ray signs are those of a deformity in the contour of the
stoma, diminution in the size of the stomach, and a tender point over
the stoma. Signs of a jejuno-colic fistula are rapid evacuation of the
stomach and filling of the transverse colon, or vice versa; entrance of
an opaque colon enema into the stomach; jejunal dilatation; tender-
ness over the lesion; irregularity of the stoma and fixation of the lesion.

Escudero2 discusses some of the disturbances associated with Gastro-
enterostomies. He mentions apparent accidents as due to several
varieties of causes; one in which the operation is performed on non-
ulcerous cases through an error in diagnosis. In one case cited, opera-
tion was unsuccessful, and blood and cerebrospinal fluid studies showed
the presence of incipient tabes which induced gastric symptoms. These
disappeared after the exhibition of cyanide of mercury. Other apparent
troubles were those associated with the ulcer, but in no way ascribable
to the gastroenterostomy, such as gastric syphilis, chronic gastritis,
nervous dyspepsia, and aerophagia, in which the ulcer was cured but the
symptoms referable to those other conditions persisted. Finally,
gastric or extragastric disturbances, subsequent to the establishment of
the gastroenterostomy, such as those due to gastric arteriosclerosis and
abdominal angina, must be mentioned. Actual accidents are due to
adhesion formation, plastic peritonitis with obstruction, and super-
imposed lesions, such as peptic, jejunal or gastro-jejunal ulcers writh
their complications, perforation, peritonitis, gastro-cutaneous, colic-
jejunal and colic-gastric fistula. The frequency of syphilis impressed
this author, and he suggests the use of mercury before and after
operation.

1 Paris Chirur., March, 1922, 14, 137.

* Rev. Assoc. Med. Argentina (Surg. Sect.), Buenos Aires, December, 1921, 34, 212.

64 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

Stevens1 discusses the surgical treatment of gastric and duodenal ulcer
with the end-results of gastroenterostomy. Except with repeated hemor-
rhage or perforation all acute ulcers should be submitted to medical
treatment by which, according to the best statistics, about 80 per cent
are cured. Repeated hemorrhage, perforation, stenosis, and those cases
which have resisted medical treatment, are indications for operation.
The internist and surgeon working together in harmony should be able
to cure 96 to 97 per cent of all gastric and duodenal ulcers.

Eusterman2 discusses the diagnostic and therapeutic aspects of late
sequela of gastric surgery. The article summarizes in a general way the
subject of the medical and surgical treatment of peptic ulcer. In the
Mayo Clinic failure to achieve cures made 228 secondary operations
necessary out of 6402 operations for all types of chronic benign ulcer.
There were 4793 posterior gastrojejunostomies alone in this series.
Gastro-jejunal or jejunal ulcer necessitated secondary operation in 57
cases. In 27 cases there was a new ulcer, or an ulcer near the site of
the old operation. Carcinoma developed on benign ulcer for which
gastroenterostomy had been done in 23 cases. In 144 out of 4793
gastroenterostomies, or 3 per cent, a secondary operation had to be
performed. Graham reported 88 per cent cures up to 1914. Since
that time, about 1800 additional cases have been operated upon with
about the same percentage of cure.

The author in this article reviews the relative merits of surgical and
medical treatment for ulcer. Consistent medical treatment is often
superior to poor surgery; likewise, the failure to institute proper post-
operative treatment is responsible for many of the disturbances following
operation.

Unquestionably the best interests of the patient are served by intelli-
gent cooperation of physician and surgeon, and we believe that the
statistics given by Eusterman enable us to predict, with a reasonable
degree of certainty, what will happen to the individual who has a gastro-
enterostomy performed under the best conditions.

O'Conor5" discussing the subject of gastroenterostomy suggests that the
patient after operation remain in bed on a rigid milk diet for twenty-
eight days, taking an alkaline mixture three times a day. Then he should
eat only two meals a day; masticate thoroughly; take in moderation an
alcoholic beverage at lunch and dinner but not at other times; rest
mind and body one hour after a meal; allow at least a six-hour interval
between noonday and evening meals; when feasible, walk in the evening
after dinner; sleep in a room with a large open window; and take regular
morning exercise. ,

Studies on the Physiology of Gastroenterostomy. Burget and Stein-
berg4 discuss the question of the physiology of gastroenterostomy.
Their studies have to do with the observation of this operation on dogs.
It has been known for a long time that the duodenal juice will regurgi-

1 Illinois Medical Journal, June, 1922, 41, 428.

2 Journal of the American Medical Association, October 5, 1921, p. 1246.

3 British Medical Journal, February 25, 1922, p. 310.

4 American Journal of Physiology, April 1, 1922, No. 2, 60, 308.

BLOOD CHANGES IN A GASTRECTOMIZED PATIENT 65

tate in the normal stomach, especially when the acidity was of any
pronounced degree. Boldyreff was the one who pointed out this mechan-
ism and a number of observers have since been able to demonstrate it.
Morse, for instance, demonstrated it in dogs; Hicks and Visher likewise
noted it in the stomachs of dogs after the introduction of 0.5 per cent
hydrochloric acid; the Rehfuss and Hawk demonstrated this same
phenomena in normal individuals.

In this series of studies the authors examined normal dogs and were
able to demonstrate that high acidities were reduced to from 0.1 to 0.2
per cent in seventy-five to ninety minutes after the introduction of acid.

Regarding the question of gastroenterostomy, Paterson claimed that
the total acidity was reduced 30 per cent and bile could be demonstrated
in 73 per cent' of patients who had this operation performed. Lemon
found a reduction of the acidity after this operation of 39 per cent total,
and 46 per cent free acidity. In this series, it was assumed that the
reduction was due to the influx of the alkaline duodenal secretion.

In this series of experiments, it was noted that, after posterior gastro-
enterostomy, duodenal regurgitation takes place within fifteen minutes
after the introduction of 100 to 150 cc of 0.5 per cent hydrochloric acid
instead of thirty to forty-five minutes as in the normal stomach, and the
acidity is reduced to 0.1 to 0.2 per cent in thirty to forty-five minutes ■
instead of seventy-five to ninety minutes as in the normal stomach.
It is generally assumed that the normal regurgitative mechanism is due
to peristalsis.

Blood Changes in a Gastrectomized Patient Simulating those of Pernicious
Anemia. Hartman.1 In this case, an individual of fifty-eight years,
the operation of total gastrectomy was performed for a movable carcina-
matous ulcer on the posterior wall of the stomach. About 1 cm. of the
esophagus was removed, and the end of the esophagus was sutured to
the lateral wall of the jejunum. A little less than two years after the
operation the patient again presented himself to the clinic, and he had
grown progressively weaker during the last year and in the last three
months, especially, before his last appearance. He complained of some
regurgitation after meals, and if this wras long continued it resulted in
the regurgitation of bile. He was also paler in appearance, and his wife
mentioned the fact that at times he was "more yellow." Most interest-
ing was the blood examination which showed hemoglobin which ranged
between 53 and 55 per cent; erythrocytes which were between 2,000,000
and 2,2S0,000; white cells between 2200 and 7600 and the color index
constant at 1.2 per cent. The differential count read as follows: Two
hundred cells counted; polymorphonuclear neutrophiles, 59 per cent;
small lymphocytes, 35.5 per cent; large lymphocytes, 5.5 per cent.
Slight anisocytosis and poikilocytosis were present. The Ribiere test
revealed an increased resistance of the red cells. The blood Wassermann
was negative. The blood was classed under Group IV. An analysis
of the duodenal contents estimated in Wilbur and Addis units showed an
increase in bilirubin, urobilin and urobilinogen. A neurological examina-

1 American Journal of the Medical Sciences, August, 1921.
5

66 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

tion showed no evidence of cord changes. The pancreatic ferment test
showed marked reduction of pancreatic activity.

The interesting point about this case was the possibility that the
absolute lack of gastric ferments might have something to do with an
incomplete or abnormal food-splitting process, the results which might
be hemolytic to the blood or detrimental to the blood forming organs.
Pernicious anemia is invariably associated with achylia. It is interesting
to note that recurring anemia and weakness were also found in one of
Moynihan's cases.

Cancer of the Stomach. Rockey, discussing cancer of the stomach, says
that 90,000 people in the United States are destroyed by cancer alone
every year. One-third of these are due to cancer of the stomach, with
34,293 yearly mortality from that source. Emphasis is laid on the
importance of a thorough examination of every individual from the
standpoint of chemical, roentgen ray, and all physical means destined
to demonstrate the possibility of a lesion. All cancer is curable by
complete excision, and none is curable when the patient has passed
the surgical possibility of complete excision.

Dume1 discusses the diagnosis of cancek of the stomach. In the
classical group of cases the loss of appetite, dislike for food, dyspepsia
and loss of weight are the initial symptoms. In the group in which
carcinoma has been engrafted on an old ulceration there is a history of
periodic dyspepsia, becoming more and more severe and often changing
in its general character.

Pain in the upper abdomen, or a change in the general character of an
old digestive disturbance, nausea and even vomiting aside from acute
digestive upsets, or loss of weight — all call for a complete study of the
individual. Tumor may or may not be felt. The acidity may remain
fairly high but is almost always reduced, and the triad of achylia, pain
and dyspepsia in elderly people nearly always spells carcinoma in the
upper abdomen. In the evolution of ulcer cases, when occult blood
fails to disappear from the stools on careful treatment, it suggests the
possibility of malignancy. Pus and blood in the empty stomach suggest
the possibility of an ulceration of a malignant process. The reviewer
feels, however, that pus and blood are frequently found in older people,
owing to the swallowing of infected material from a pyorrhea or post-
nasal infection. Furthermore, in these cases roentgen-ray examination
shows characteristic defects.

Taylor and Miller,2 in an analysis of gastric cancer and its asso-
ciation with preexisting ulcer, discuss the results of their studies
of 182 cases of gastric cancer. They found a suggestive history of pre-
existing ulceration in only 17 per cent, and they included in this list
all those cases that had digestive symptoms other than the usual ulcer
syndrome, apart from the digestive disturbances of childhood. This
is interesting when it is realized that several years ago another well-
known gastro-enterologist was able to demonstrate such a history in
only 23 per cent of his rather extensive material.

1 Nebraska State Medical Journal, May, 1922, 7, 159.

2 American Journal of the Medical Sciences, December, 1921.

CANCER OF THE STOMACH 67

Some interesting data was obtained on this material. Eighty-five
per cent were between forty and sixty-nine years of age; only 2 patients
were in the third decade, 1 twenty-four and the other twenty-seven.
Tain occurred in 55 per cent and vomiting in 17 per cent. Other
symptoms were "stomach trouble or indigestion," loss of weight, belch-
ing, a lump in the abdomen, weakness, constipation and pain in the back.
While 55 per cent gave pain as the chief complaint, 88.5 per cent stated
it was one of the prominent symptoms, and of this number 94.4 per cent
complained of pain in the epigastrium; 82 per cent were constipated.
Pain in the back was seen in 29 per cent of pyloric cancers, and of all
those who complained of pain in the back 80 per cent had involvement
of the pylorus. With pyloric cancer the average free and total acid
findings were 15.5 and 45, but there was definite retention. When
cancer was situated elsewhere figures were low but there was no reten-
tion. A positive diagnosis with the roentgen ray was made in 96.8 per
cent of cases.

Prentis1 discusses the inhibitory effect of secretin on the forma-
tion of gastro-intestinal cancer. It is its presence in the duodenal
mucous membrane that prevents the formation of cancer there; and it
is rather significant that there is no secretin present in the esophagus,
stomach or large intestine. In other words, cancer is most frequent
where this substance is least frequent. The liver is the largest, and the
presence of secretin in the portal blood explains the infrequency of
primary carcinoma of the liver; and also the fact that primary carcinoma
of the pancreas is three times more frequent than primary cancer of the
liver. The use of secretin is suggested therapeutically.

Bennett and Dodds2 discuss the question of certain conditions associ-
ated with deficient secretion in the upper digestive tract. These authors
briefly summarize their findings as follows: (1) Complete absence of
the gastric HC1, and hence all active gastric ferments, is frequently
encountered in healthy persons. (2) A similar condition is frequently
seen in dyspepsia subjects. (3) In rare cases an increased amount of
mucus is seen, sometimes indicative of a true gastritis, and not infre-
quently due to pulmonary or nasopharyngeal disturbances. (4) In
other rare cases achylia offers delayed emptying of the stomach, and such
patients usually show visceroptosis. (5) In a patient who is shown
to have pancreatic sclerosis, the fall of alveolar C02 tension, which
normally occurs after the passage of food through the pylorus, is absent.
(6) In patients suffering from pernicious anemia, there is, in addition to
a complete achylia gastrica, a marked diminution in the pancreatic fall
of alveolar C02' tension. (7) Such patients have clinically been shown
frequently to have pancreatic insufficiency. (8) Similar pictures of
alveolar C02 tension and lack of acidity have been found in severe
anemia to be due to a secondary blood condition. (9) At least four
types of pictures are given by the laboratory examination of gastric
cancer, (a) First, a type of extreme pyloric stenosis; (6) a type charac-

1 Medical Record, April 1, 1922, 101, 542.

2 Lancet, June 10, 1922, 1138.

68 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

teristic of cachexia ; (c) a type of excessive secretion of mucus ; and (<7) a
type difficult to differentiate from benign achylia.

Gastric Juice. Methods of Measuring Acidity. Lauz1 calls
attention to the necessity of examining the functional alterations of the
secretory mechanism, not alone in ulcer and cancer, but in many of the
mild affections of the stomach.

The actual acidity is the measure of the "active" secretion. It
measures the number of free hydrogen ions, regardless of the form or
derivation of the acid, whether hydrochloric (the most important),
lactic, phosphoric, or even acetic, found only in the diseased stomach.
It is the actual acidity on which peptic digestion depends, and it is this
acidity which measures digestive power. The author claims that
titration procedures are not as good as calorimetric procedures for
measuring this acidity. The "potential acidity" is the number of
hydrogen ions which are not isolated or free, but which are replaceable.
They are determined approximately by the difference between the total
and the real, or "actual," acidity, as mentioned above. It gives the
quantity of bases present capable of entering into combination.

Total acidity is the sum of the two acids, free, or actual, and poten-
tial. It is difficult to determine accurately, and varies with a multitude
of causes. The author believes the determination of the free hydrogen
ion, or "actual," acidity, the most important.

The value of fractional analysis of the gastric contents has been
questioned by a series of communications; viz., those of Gorham,
"Wheelom, and Koppleman, who have sought to discredit fractional
analysis on the basis that there was a variation in the gastric acidity
in the various parts of the stomach.

Gorham2 discusses the variation of acid concentration in different
portions of the gastric chyme and its relation to clinical methods of
gastric analysis. He used a dry test-meal of shredded wheat biscuit
and 400 cc of water, after the removal of the fasting contents. The
tube was then reintroduced into the stomach forty-five minutes after the
administration of the meal and the contents aspirated in 10 cc portions
in rapid succession until the stomach was empty, the last portion being
obtained after the inflation of the stomach with air, the patient pre-
sumably lying supine. These experiments were carried on in 65 cases,
and in a few cases successive test-meals were given and the stomach
completely emptied in one-, one and a half- and two-hour periods,
The author attempts to show in this manner that the different portions
of the gastric chyme vary widely in acid concentration, and therefore
small samples, such as obtained by fractional analysis, where only a small
portion of the contents is obtained for analysis, is not, in the majority of
cases, representative of the gastric chyme. He furthermore points out
the fact that the sample obtained in this way is dependent entirely on the
position of the tip, as well as the particular moment in which the speci-
men was obtained. He furthermore assumes, without any demonstra-
tion to ascertain the fact, that the position of the tip is a constantly

1 Schw. mod. Wchnsehr., 1921, 17, 1057-1066.

2 Archives of Internal Medicine, April 15, 1921, p. 435.

GASTRIC JUICE 69

changing one, owing to the change in the size and position of the stomach,
and presumably, although no evidence is offered, that the shortening
and lengthening of the stomach from gastric contraction alters the posi-
tion of the tip. Furthermore, this author mentions the fact that this
phenomenon explains in part the great variety of acid curves obtained
by the fractional method. In his conclusions, he mentions (1) the fad
that a method of gastric analysis is introduced for determining varia-
tions of the acid concentration in different parts of the gastric chyme
after a test-meal. (2) That the gastric chyme is not, in the majority of
instances, a homogeneous mixture and that different portions may vary
markedly. (3) He claims that a small portion removed in that way
is not necessarily representative of the gastric contents; and, finally,
attention is called to the fact that a physiologic principle, such as was
mentioned above; viz., the alteration in the position of the tip, explains
in part the great variety of curves obtained by the fractional method.

A second observer, Wheelom,1 goes into this matter even more
thoroughly, in which the results reported are based on 290 gastric sample
titrations from 04 normal medical students. In this group of cases,
three methods of procedure were employed: (1) The usual one-hour
test following the complete removal of the stomach contents at one
time. (2) The fractional method in which withdrawal of the contents
was made every fifteen minutes following an ingestion of the test-meal.
(3) A method recently described by Gorham such as has been mentioned
above.

In this series of tests, the 2 slices of bread and 500 cc of water were
employed for the meal.

While this series of studies is more complete than that of Gorham, the
conclusion which the author reaches is that the acid concentration of the
gastric contents is not, in the majority of cases, (19 young men) constant
in all parts of the gastric contents at the end of one hour. (2) That the
withdrawal of the gastric contents for purposes of determining the acid
concentration, the type of the meal, the position of the tube tip and the
duodenal regurgitation are factors which militate the acceptance of
fractional curves as indicative of the secretory functions of the stomach.
In this series of studies, comparisons are made between the various
methods of examination.

These columns are no place for a critical reply to these investigations,
nevertheless the reviewer feels obligated to point out one or two facts of
importance, even though the reply to such criticism will be forthcoming
in the future.

The observations of these investigators seem to be based upon the
fact that there is a variation of the gastric acidity in the stomach. This
idea is not new, nor is the idea that there is lack of homogenity in the
gastric contents new. It is obvious that the homogenity of the gastric
contents will depend largely on the type and nature of the contents, and
the duration and character of gastric work. A meal with solids of
different kinds will obviously reveal less uniformity than a meal which

1 Archives of Internal Medicine, November, 1921, 28, 1613.

70 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

is largely liquid in character. The fractional tube was devised to meet
a need; viz., a method of gastric intubation which was far more pleasant
and comfortable than the commonly-accepted tube, and, furthermore,
was a method by which a tube could be left in place over long periods,
and the characteristics of the gastric contents thoroughly studied. In
fact, it was by this tube that these observers were able to demonstrate
variations in the character of the gastric contents. These observations
are both incomplete and lacking in the very details which they themselves
acknowledge. In the first place, they fail to determine accurately the
position of the tube. Had they done so, and observed the ordinary
precautions, it would have been found that if the tube was passed to a
certain point the tip is almost always in the pyloric antrum in the supine
or upright position. This has been the experience, not only of the
reviewer, but also of other investigators with whom he has been in
contact. In the second place, the idea of removing successive fractions
of the gastric contents does not reveal the nature of the contents at the
present moment of removal. In previous studies we were able to demon-
strate marked variations in the gastric acidity during the early periods
of digestion, which are commensurate with what we were expecting to
find before more or less equilibrium was established. These variations,
however, are far less pronounced as digestion proceeds, and the mixture
becomes homogeneous. In some of the earliest studies which were
made, in the beginning of digestion, removing samples at one-minute
intervals, we were able to demonstrate a marked accretion in gastric
acidity. Furthermore, other observers were able to demonstrate that
while there are some variations in the gastric contents, these variations
are of minor importance and do not detract from the main fact, which
is that by means of the fractional tube it is possible to gain a fairly
good and accurate picture of the evolution of gastric digestion. These
authors have in no way been able to demonstrate the falsity of the
principle which gastric analysis clearly emphasizes, and that is the fact
that gastric digestion is a continually changing cycle.

In communications which we shall present in the future, these criti-
cisms will be fully dealt with, but the reviewer is of the opinion that for
a representative study of the evolution of gastric digestion through
all its phases, no method offers more possibilities than the commonly
accepted method of fractional analysis.

Friedenwald1 discusses the result of a series of fractional analyses of
the gastric contents in 210 cases and covering a wide diversity of clinical
conditions.

The conclusions are as follows : (1) By means of fractional analysis we
can study the entire cycle of digestion, both as to secretory and motor
activity of the stomach. (2) By complete aspiration at any period of
digestion, we can obtain definite information regarding the amount of
the secretion. (3) In duodenal ulcer, the acidity is usually higher than
in any other condition. There is a rapid, prolonged rise followed
frequently by a fall and a second rise, although there may be a con-

1 Southern Medical Journal, September, 1921.

GASTRIC J VICE 71

tinuous prolonged rise. The highest acid appears frequently after one
hour. Blood is occasionally found, and the rapid evacuation is rare.
(4) In gastric ulcer there is no typical curve of gastric acidity, although
a fall, followed by a second rise, is not infrequent. Hyperacidity is
usually present, although there may be low or normal acidity. The
highest acidity appears one hour afterward in most cases. There is
usually delayed motility in gastric ulcer. (5) By means of fractional
analysis, the acidity in any period of the digestive cycle of ulcer may be
noted. ((5) The effect of an ulcer cure can be followed by fractional
analysis. In about one-half of the cases observed, there was no posi-
tive reduction of acidity, even though clinical improvement was noted.
(7) In pyloric stenosis there is usually high acidity over the whole period
of digestion, with delayed motility. (8) In most cases of carcinoma one
finds a typical achylia frequently associated with delayed motility, and a
rather high total acidity, with lactic acid and blood. The Wolf-Yung-
hans test is positive in these cases, considerable amounts of albumen
being present in three-quarters of an hour, and the amount of albumen
being markedly increased within one and a half hours. (9) Cases of
chronic gastritis present the same characteristics as those usually ob-
served in simple achylia. The total acidity is usually higher, and, in
addition, mucus is obtained which is not frequently observed in achylia.
The motility of the stomach is often delayed. (10) In gastric syphilis
the curves of acidity are similar to those observed in cancer, the total
acidity is high and there is a complete achylia. The stomach empties
itself rapidly. (11) Fractional analysis of the gastric secretion, accord-
ing to the Rehfuss method, is extremely important in all cases of achylia
gastrica, inasmuch as by means of this method one can readily dif-
ferentiate true achylia from the spurious form. This differentiation is
extremely important, inasmuch as many of the false achylias present a
very high hydrochloric acid indication, sometimes even marked hyper-
acidity. These cases are in reality cases of delayed hyperacidity. In
true achylia, hydrochloric acid is absent in every specimen, the total
acid is low and there is marked hypermotility. In pernicious anemia
one observes the typical features of a true achylia. (12) In nervous
gastric effects, one observes a tendency to lower acid and achylia, while
in chronic appendicitis hyperacidity is usually observed. (14) There
is no pathognomonic curve absolutely distinctive of any gastric lesion.
E. C. Dodds1 discusses an extremely interesting phase of gastric
secretory studies. In this communication it is pointed out that the
tension of carbon dioxide in the alveolar air undergoes certain definite
changes in response to the amount of the secretion poured out in the
stomach, and also a commensurate change from the outpouring of the
alkaline pancreatic secretion. Samples of the alveolar air are collected
after forcible expiration before breakfast, and the percentage of carbon
dioxide determined by an analysis with Haldane's apparatus. The
patient is then given a test-meal, and fifteen-minute interval examina-
tions are made both of C02 and also the gastric secretion. He foimd

1 Lancet, September 17, 1921.

72 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

rather characteristic curves for various conditions, and suggests that the
results demonstrate the total amount of acid or alkali poured out.
In studying the curve the effect of the outpouring of acid, and then the
compensatory outpouring of alkali, is noted. This work is very suggest-
ive, and there occurs in a former number of the International Journal
of Gastroenterology a similar article. This subject, however, requires
thorough investigation, but it is hardly possible that such methods can
supplant the actual study of the gastric contents, inasmuch as the
determination of gastric acidity is but one of the points to be worked out.

Lockwood and Jacobson,1 discuss the significance of successive aspira-
tion of the gastric contents. According to these authors, the method of
fractional analysis has been extensively adapted, and, according to the
literature, one almost universally accepted as giving an accurate picture
of stomach work throughout all its phases. Doubt, however, is thrown
on its value by Gorham, who assumes that, for the method to be correct,
each specimen must retain the stomach contents as a whole at that
particular time. Wheelom makes the same assumption. Both claim
that the gastric contents are not a homogenous mixture. This was
shown by aspirating the whole of the contents in portions of 5 to 10 cc
and finding a variation in the acid content of the different specimens.

These authors, however, from their observations on 45 cases, came to
the following conclusions: (1) Different portions of the stomach con-
tents aspirated in quick succession through a small tube show a moderate
variation in physical character and acid contents. (2) The tube tip
usually rests near the outlet of the stomach, the patient remaining
seated or supine. (3) When small amounts are aspirated at regular
intervals, one gets the cycle of events as they occur in the pars media
and the pars pylorica. (4) Fractional gastric analysis does, in the
majority of cases, give us fairly accurate information on the normal or
pathologic physiology of the most important functions, and is our best
method of determining food and drug action in the stomach.

Another author, Knapp2 discusses the standardization of the test-meal.
His conclusion is that there is a definite lack of standardization of test-
meals, for which there is no evident good reason. The Ewald meal,
weighed accurately, is the one suggested. The quantitative type of
test-meal is recommended by this author. He gives a list of 18
institutions, and tabulates some important statistics regarding the
method of analysis used by those institutions. The different meals
vary considerably, although almost all of them consist in some form
of carbohydrate and water. In 12 institutions the fasting stomach is
examined; in 10 institutions, the fractional method is employed; in
1 institution the single examination is made in thirty minutes; in
8, it is made in forty-five minutes; in 6, it is made in one hour. In
14 cases the entire residuum of the meal is aspirated. In almost every
instance phenolphthalein, and Topfer method of analysis, is employed.

Pemberton3 discusses the diagnostic value of the fractional meal. This
article discusses, in a general way, the question of the analysis of the

1 New York Medical Journal, June 7, 1922. 2 Ibid.

3 British Medical Journal, July 1, 1922, p. 7.

ULCER OF THE DUODENUM AND APPENDICITIS 73

curves, including the rate and nature of secretion which depends upon
the amount of mechanic or psychic stimulus which is brought to hare
on the gastric mucous membrane, and it can be assumed, as a general
rule, that, apart from slight psychic disturbances, these two factors,
the rate and the amount of secretion, may be assumed to be the
property of the particular stomach which is being examined. Further-
more, the next point is the question of the rate of evacuation, and,
finally, the question of the degree of neutralization or dilution brought
about by regurgitation from the intestines. Quoting the author, leav-
ing out all account during possible but unknown factors, such as
the part played by the vascular system, some sort of general
relationship may be formulated between the above factors and the
resulting acid concentration of the fluids withdrawn from the stomach.
If "C represents any point on the total acidity curve, and S would
represent the gastric secretion, and E would represent the evacua-
tion, and R the degree of intestinal regurgitation, then it would
appear that C varies as S and indirectly as E and R. This relation
cannot be considered as being in any way exact, although the two
associated factors E and R would appear to operate almost at once. It
is certain that we reach higher values at the later period. This author
mentions six types of curves, and the author is of the opinion that this
method of examination is at least admissible as an aid to diagnosis.

Observations on Gastric and Duodenal Motility in Duodenal Obstruction.
In an interesting case of small intestinal obstruction affecting a child,
aged seven months, Wheelon1 demonstrated some interesting facts re-
garding gastric and duodenal motility. The illness began with vomiting,
and after a period of protracted fever, vomiting and some temperature
rise, the child was submitted to roentgen-ray examination, where the con-
dition was diagnosed as an obstruction or kink at the level of the liga-
ment of Treitz, at the duodeno-jejunal junction. At operation, however,
the obstruction was due to incarceration of the bowel in a peritoneal sac
in the lower ilium. In this case evidence is brought forth to support
the fact that the acid control of the pylorus is not the only factor in the
control of pyloric action. In this case, too, it was demonstrated that,
in spite of some difficulty in the egress of material from the duodenum,
the stomach was able to fill up the duodenum and even induce marked
distention. Beyond a certain point, however, the duodenum regurgi-
tated material back into the stomach. Vomiting unquestionably is
associated wTith duodenal distention.

Relation Between Ulcer of the Duodenum, Appendicitis and Cholelithiasis.
In this discussion, Schutz2 recalls the ideas of Moynihan, Rosle and Kel-
ling on the frequency of association of ulcer of the duodenum, appen-
dicitis and cholelithiasis. Opposed to these, the author cites his own
observations as well as those of Mayo, Schrijver and Nowak on the rarity
of these associations. There is no question of the frequent association
of perivesicular affections with those of ulcer of the duodenum; but the
association is almost always a contiguous inflammation and not a true

1 Journal of the American Medical Association, October 29, 1921, p. 1404.

2 Wien. klin. Wchnschr., October 6, 1921, p. 484-485.

74 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

and spontaneous infection of the biliary passages. More often these
perivesicular changes are quiescent and induce no disturbance, but not
infrequently they can simulate an attack of biliary colic which lends
color to the supposed association. On the other hand, cholelithiasis is
much more frequent with women, and duodenal ulcer with men.

As to the relationship between duodenal ulcer and appendicitis, in
many instances the appendix, on removal, is anatomically normal, and
the removal has little effect on the subjective symptoms, When, how-
ever, the appendix is definitely diseased, its removal causes a cessation
of all pain.

It is rather remarkable that appendicitis seems to decrease as we know
better ulcer of the duodenum. This question is one which requires
exact study.

In the reviewer's opinion, there is no doubt that the association does
exist at times, but that it is as frequent as we are led to believe from
certain publications is hardly within keeping with the facts; and yet
the incidence of appendectomy without relief is altogether too large in
cases of ulcer of the duodenum.

Physical Characters and Enzymatic Activities of the Duodenal Secretion.
McClure, Wetmore, and Reynolds1 discuss in this communication the
characteristics of the duodenal secretion during gastric digestion in
normal young men. Emptied on the fasting stomach, the Rehfuss
tube was inserted, and the patients examined with the fluoroscopic
screen until it was determined that the tip was in the second portion of
the duodenum. They were then fed one of five types of meals: (1)
300 cc of a mixture of milk, water, and cottage cheese; (2) 300 cc of 20
per cent cream; (3) 300 cc of 0.5 per cent cooked cornstarch solution
in which was dissolved 15 grams of lactose, and (4) 300 cc of tap water.
To each meal was added 40 grams of barium sulphate. A fifth type of
meal consisted of 40 cc of 20 per cent cream and 10 grams of barium
sulphate. The presence of the barium salt permitted fluoroscopy of
the stomach and duodenum during the process.

After the subject had ingested one of these meals, he was turned on
his right side and a small amount of the duodenal contents aspirated,
after which it was obtained by syphonage. The amounts obtained in
this manner were never less than several hundred cubic centimeters, and
the times varied from two to four hours, depending on the time interval
of gastric evacuation. Water left the stomach in from one to one and
a half hours; starch and lactose in from one and a half to two and a
half hours; the milk and cottage cheese mixture in from three to three
and a half hours; the 300 cc cream mixture in from four to five hours,
while the 40 cc cream left in about one hour's time.

Duodenal contents collected after the water meal were greenish-yellow
the first hour, golden-yellow in the second hour; those of the first hour
being slightly viscid, those of the second hour more so. The starch-
lactose mixture gave yellowish-brown specimens during the first hour

1 Journal of the American Medical Association, November 5, 1921, No. 19, 77, 1468.

DUODENAL DIVERTICULA 75

and golden-yellow during the second hour. The contents with this
meal were somewhat more viscid than those obtained with water. The
contents with the milk, water and cottage cheese meal were deeply
yellow and more viscid than any of the above-mentioned samples. The
300 cc cream meal gave deep golden-yellow samples, with the exception
of the first two hours when they were greenish-yellow. Finally, with
the 40 cc cream meal the specimens were greenish-yellow during the
first hour, and lemon-yellow during the second hour. The contents with
the cream meals were much more viscid than those obtained with any
other meal, and these findings suggested that differences in color and
viscosity of the duodenal fluids in some way is dependent on the kind
of food ingested.

In determining enzyme action, the use of mixtures of disodium
phosphate and potassium acid phosphate solutions, whereby the degree
of alkalinity necessary to bring about uniformity and proportionality
of enzyme action had been obtained. In these studied, protein activity
was ascertained by allowing the duodenal contents to act upon a soluble
solution of casein. The amount of digestion which occurs is estimated
by an adaptation of the method of Folin and Wu for the determination
of non-protein nitrogen. Amylase activity is estimated by the action
of the duodenal contents on starch solution. The amount of sugar
formed is estimated by the method of Folin and Wu for the deter-
mination of sugar in the blood. Lipolytic activity is estimated by the
action of the duodenal contents on a true emulsion of cotton-seed oil, and
is represented as the number of cubic centimeters of tenth normal sodium
hydroxide necessary to neutralize the degree of acidity developed.

The degree of acidity, that is to say the hydrogen-ion concentration
of the duodenal contents derived from the various types of meals, was
also determined.

Duodenal Diverticula. Andrews,1 in a short but interesting summary,
reviews the literature of duodenal diverticula. An analysis of Case's
papers on this subject has been made in these columns, and it will be
recalled that very extensive studies were then reported regarding
diverticula through the entire length of the digestive tract. Andrews
point out the fact that our knowledge of duodenal diverticula really
belongs to two periods, one the mortuary period from 1710-1910, when
in reality the condition was viewed as an interesting deformity on the
mortuary table— and a second (or roentgen-ray period) in which the
clinico-pathologic evidence likewise markedly increased. A third, or
coining period, is one in which we may view the evolution of the
operative treatment for this condition; and where broad problems of
etiology, its association with ulcer pathology and other similar problems
must be worked out.

After a brief but comprehensive review of the literature, the author
discusses several phases of the subject. It was noted, for instance, that
duodenal diverticula belonged to the acquired, rather than the con-

1 Journal of the American Medical Association, October 22, 1921, No. 17, 77, 1309.

76 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

genital, deformities, especially inasmuch as they belong to the latter
half of life; although Shaw reported one case in a new-born infant.
They were usually single and were most often found near the papilla of
Vater. They were most commonly 0.5 to 3 cm. in diameter. Fre-
quently they were covered over with the intact duodenal mucosa. The
direction has been various — forward, backward, upward or downward.

In the discussion of etiology, the weak points in the duodenal wall are
mentioned, such as the insertion of the vessels, especially the veins,
which constitutes a point of lessened resistance. Again, inflammatory
disease and round ulcer may weaken the intestinal walls. One cannot
ignore the frequency of these manifestations at the head of the pancreas,
where, according to Kath, the musculature is weakened, possibly by the
duct and large vessels penetrating its wall. In Linsmayer's 1367
necropsies, 45 cases, or 3 per cent, were found; and Buschi noted 2 per
cent (or a total of 73 cases), 54 of which showed clinical symptoms.
Case reported 6847 examinations with 85 cases, some 1.2 per cent
discovered by roentgen-ray examination. In Andrews studies of
roentgen-ray examinations of 2200 stomach cases, 300, or 14 per cent
showed deformity of the duodenal canal, and only 26, or 1.2 per cent
resembled diverticula.

These deformities range all the way from slight kinks or angulation
of the tube, caused by dragging or outside pressure, to total obliteration.
The author makes the statement— which we believe to be of great
importance — that for the surgeon and internist "no laboratory report
and no roentgenogram can teach him as much as viewing the moving,
living picture 'with his own eyes."

Intubation and Visualization of the Duodenum in Suspected Lesions
of the Pylorus, Duodenum and Gall-bladder. In this communication
Palefski1 seeks to determine whether defective filling of the duodenum
is due to ulcer, pericholecystic adhesions, pressure from neighboring
organs, or caused reflexly from the intestines and other abdominal
organs. This question is one which has puzzled every gastro-enterol-
ogist, and is of paramount importance in the diagnosis of upper right
quadrant affections. The author quotes Lockwood who says, "over
four-fifths of the duodenal ulcers diagnosed by the roentgen ray have
turned out to be nothing more than chronic appendicitis."

(The reviewer considers this statement altogether exaggerated, and
suggests that an expert opinion of duodenal ulcer, when the lesion is
well-defined, is ulcer in over 90 per cent of cases.) In fact Charles
Mayo informed the reviewer that Carman's diagnosis of ulcer of the
duodenum was right in 96 per cent of cases.

Palefski proposes to study this subject from the two-fold standpoint of
duodenal intubation and fluoroscopic examinations. By means of intuba-
tion, the examination of the duodenal secretion for its physical, chemical,
microscopic and bacteriologic properties is made. A change in the
normal color and transparency is noted, the persistent presence of blood

1 American Journal of the Medical Sciences, 1922, 163, 385.

NON SUPPURATIVE AMCEBIC HEPATITIS 77

is ascertained, an increase in mucin epithelial cells, or bacteria signify-
ing inflammation of the duodenum or biliary passages, is noted.

Palefski passes the tube into the duodenum, aspirating samples, and

then injects a barium suspension, takes exposures and observes the
condition of affairs. Prepyloric ulcers and adhesions frequently delay
the passage of the duodenal tube. The author says that he has seen
fairly large lesions of the cap which showed no roentgen evidence
whatsoever. On the other hand, defective filling of the duodenum is,
in his experience, less frequently due to duodenal ulcer than to peri-
duodenal cholecystic adhesions. A case with high gastric acidity one
hour after a meal, blood in the duodenal contents, delayed gastric
evacuation and a normal horseshoe course of the duodenal tube, may be
safely regarded as ulcer of the duodenum, whether or not there is defec-
tive filling of the duodenum.

The point which the reviewer mentioned in one of his communica-
tions, namely, the simultaneous appearance of bile and blood in the
gastric contents, Palefski holds to be due to the fact that the tip of the
tube has gone into the duodenum. This is not always the case, however.

A case with gastric symptoms showing tenderness in the right hypo-
ebondrium, normal or subnormal gastric acidity, delayed gastric evacua-
tion after a mixed meal, a distorted course of the duodenal tube with,
or without, defective filling of the cap, may safely be regarded as chronic
cholecystic adhesions. Most of these cases show gastric hypermotility
six hours after an opaque meal, turbidity, increased mucin, epithelia
and bacteria in the duodenal juice, and there is usually a history of
constipation. Regarding duodenal intubation after gastroenterostomy;
the duodenal tube is allowed to pass through the anastomosis and in
perijejunal adhesions the course of the jejunum is distorted and twisted.

Non -suppurative Amoebic Hepatitis. Three forms of non-suppurative
amoebic hepatitis are described by Paisseau.1 Acute abortive amoebic
hepatitis, chronic amoebic hepatitis, and amoebic cirrhosis.

The acute abortive form studied by Chauffard and Francon resembles
abscess, but all the symptoms disappear after the exhibition of emetine.
Ordinarily, the response to medication is rapid. Chronic amoebic
hepatitis is characterized by its subdiaphragmatic location, hepatic pain
more diffuse than that of abscess, pain referred to the right shoulder,
often a dry cough and not infrequently a pleuro-pulmonary reaction.
The liver is not much enlarged.

The dysenteric exacerbations do not always coincide with the hepatic-
exacerbations, although there is more or less constant diarrhea. These
patients, anemic and emaciated, have the appearance of chronic malaria.
The differential diagnosis must be made from hepatic congestion,
pleuro-pulmonary affections and, finally, malaria. The search for cysts
in the stools is often negative, but it is the rapid response to emetine
which leaves no doubt of the diagnosis.

Regarding the amoebic cirrhosis form, there is little doubt that this
exists and may be distinguished from other forms of cirrhosis by its
response to emetine.

1 Paris Medical, 1921, No. 14.

78 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

LIVER.

Regarding the question of liver disease, a number of contributions
have occurred on the question of functional testing of the liver. The
difficulties in this line are due to the fact that various functions of the
liver may be impaired, and, again, there may be only a partial func-
tional disturbance. Furthermore, certain organic diseases of the liver,
attacking only limited parts of the parenchyma, may attain consider-
able size before any noteworthy change is apparent in hepatic function.
Retzlaff1 discusses the various methods for testing liver function.
Regarding the glycogenic function, considerable normal variations may
occur in the blood-sugar on the one hand; while, on the other hand,
abnormally diffuse inflammation, or even chronic disease of the liver,
may occur with a normal blood-sugar. Certainly diminished glucose
tolerance is not necessarily a sign of parenchymatous injury. In-
creased levulose and galactose excretion are more likely to point to
li^er injury. A positive finding usually indicates diffuse liver injury,
while circumscribed processes, like those due to carcinoma, are usually
negative in their effects. The urea function is often apparently un-
affected, even in severe injuries, although Hetenyi has shown that the
synthesis of ammonia salts into urea occurs much more slowly with the
diseased liver. The administration of amino-acids with increased
excretion in the urine is found in syphilitic, fatty and cirrhotic livers;
while increased amino-acid excretion after hydrazin sulphate also
indicates disturbance of the liver. An increase in blood-nitrogen is also
a bad sign in liver injury. The other methods of testing liver function
are discussed. The question of icterus naturally brings up the discussion
as to whether the liver is necessary to the production of icterus. Cer-
tainly, bilirubin can be developed from blood pigments. The presence
of both bilirubin and bile acids should be sought in the urine. The
ultramicroscopic demonstration of "hemokonies," or fat bodies, one-
half an hour after the ingestion of fat is likewise important. In the
diminution or absence of bile acids there are no hemokonies in the
circulating blood. The diazo reaction gives varying results, depending
on whether the reagent is added to the serum in an alcoholic solution
(such a reaction is due to icterus caused by obstruction) or whether it is
added to the serum in aqueous solution; the latter reaction being seen in
normal blood and in hemolytic icterus.

The duodenal secretion is examined for bile acids, pigment, cholesterol
and urobilinogen. Increased pigment may be found in icterus owing
to increased blood disintegration, but is absent in hepatic icterus if
secretion of bile is lessened. Many points influence the cholesterol
content. A negative urobilinogen test definitely rules out heterogenic
bile-duct infection. The author mentions the fact that peptone or
magnesium sulphate give pure bile, but does not believe that gall-bladder
bile can be obtained without liver bile; furthermore, the results after
cholecystectomy seem to contradict the value of this test. He is not

1 Berlin klin. Wclmschr., April 22, 1922, 1, 850.

LIVER 79

much impressed with the value of the alimentary urobilinogenuria test,
as the tolerance varies widely, even with normal people. The Widal
"hemoclastic crises" test, based on the observation that intravenous
peptone injections cause vascular crises with leukopenia and reduction
of blood-pressure and blood-coagulability, is suggestive but is not
confined to peptone. In fact leukopenia after administration of food
in an adult generally indicates liver injury. The Widal test, as com-
monly performed, consists in the administration of 200 cc of milk, which
produces in subjects suffering with hepatic disease an appreciable
leukopenia instead of the normal digestive leukocytosis.

Dresel and Lewy1 observed the same result with 50 gm. of cane sugar.
These authors found a sudden marked diminution, especially of the
lymphocytes, in paralysis agitans.

Mauriac2 questions the fact as to whether leukopenia alone is evidence
of digestive hemoclasia in hepatic insufficiency. Even normally there
is considerable variation, as much as 5000 in the leukocyte count.

Roth and Hetenyi3 did not observe these crises, characterized by
leukopenia and a fail in blood-pressure, in patients without liver disease
except in two cases of asthma. Analogy is suggested between digestive
hemoclasia and anaphylaxis, but the former occurs without symptoms
and may be due to any form of protein, while anaphylaxis can only be
produced with specific proteins. These authors do not doubt the
association of digestive hemoclasia with liver function, but feel that its
positive significance is very much overestimated while a negative out-
come does not rule our liver disease.

Meyer-Estorf3 also discusses the question of hemoclasia. The test
is performed with 200 cc of milk, given on an empty stomach after the
patient has had a leukocyte count. Another count is made in twenty
minutes. A reduction in leukocytes, and particularly in the neu-
trophilic leukocytes, is noted. The author believes that the degree of
leukopenia, on the whole, parallels the liver injury. But there are a
group of cases in which there is icterus with leukopenia, a digestive
leukocytosis and green p-dimethylamidobenzldehyd reaction.

Lepehne,5 in discussing functional liver testing, discusses the chromo-
diagnosis with indigo-carmin, the bile acids in the duodenal contents
and the urine, and Falta's test for urobilinogenuria. After the adminis-
tration of indigo-carmin intravenously, usually within thirty-five
minutes, the bile suddenly turns green, and this continues for an hour
or more. In catarrhal jaundice, and icterus from cholangitis, no indigo
is found in the bile, but on resolution it reappears. The method is not,
however, very satisfactory; it resembles the tetrachtophthalein test
which Aaron, and others, studied with the duodenal tube.

Regarding bile acids; the use of the sulphur test with normal urine
and normal duodenal contents is always negative. This is not the
case with icterus. An interesting case of cholelithiasis was presented

1 Ztschr. f . d. ges. Med., January 29, 1922, 26, 87.

2 Jour, de med. de Bordeaux, February 10, 1922, 94, 83.

3 Berlin, klin. Wchnschr., May 20, 1922, 1, 1046.

4 Klin. Wchnschr., April 29, 1922, 1, 890.

5 Mtinchen. med. Wchnschr., March 10, 1922, 69, 343.

80 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

in which bile gave low acid findings, and urine was positive for bile
acids. Four days later it disappeared from the urine and was increased
in the bile.

Regarding the urobilinogenuria: Falta, Hogler and Knoblock claim
that a dose of 3 gm. of dried ox bile produces alimentary urobilinogenuria
in persons affected by disease of the liver. Lepehne found this test
unreliable. He also found considerable daily variation in spontaneous
urobilinogenuria. It may be due to an increased flow of bile after the
noonday meal. In Falta's test, the powder should be given in the
morning and the examination of the urine should be made at 3 p.m.,
as the morning urine of some individuals with hepatic disease may be

negative.

Biscons and Rouzard1 discussed the modifications of the serum in
hepatic disease. This study is based on 274 cases. The blood was
obtained by venous puncture every morning after breakfast and included
tests for cholesterol, cholemia, glycemia, blood-urea and the urea
secretion constant. It was noted that when the disturbance was
due to an extra-hepatic factor, such as hemolytic icterus or obstruc-
tive icterus, cholesterolemia and bilirubinemia appeared to be modi-
fied only in the beginning. If, however, the trouble persisted for
some time, and the hepatic cells be involved, then azotemia and
glycemia show modifications. In hepatic congestion, with little altera-
tion of the liver parenchyma, blood nitrogen is increased ; in the degenera-
tions and cirrhosis, urea is decreased, but of course in interpreting these
findings it is essential to consider the "renal factor." A measurement
of renal permeability will enable one then to determine the "urea
secretion constant." In cholelithiasis hypercholesterinemia (unaccom-
panied by any marked increase in bilirubinemia) was observed The
reverse is true in hemolytic icterus, where hyperbilirubinemia was
observed without an increase in blood cholesterol.

The diazo reaction as a test for bilirubin in the blood was mentioned
above. Several years ago, van den Bergh, and others, found that the
bilirubin in the bile gives the diazo reaction immediately, without the
addition of alcohol. This was in direct contrast to the bilirubin obtained
from gall stones which requires alcohol. These observers then showed
that the blood of normal persons gave the diazo reaction without alcohol
after a short time'. It begins in about thirty seconds and continues to
increase. The blood of obstructive jaundice, however, gives the
reaction immediately, without the addition of alcohol. This was called
the " prompt direct reaction." It was noted that there were really two
phases; one an immediate and distinct change, and the other becoming
more marked after a few minutes. This enabled van den Bergh to
divide the result into two forms; one in which the bile passed through
the liver cells and reached the blood by absorption from the bile pas-
sages (obstruction type) producing a prompt reaction; and the other
the bilirubin formed outside the liver producing the retarded direct
reaction.

Meyer and Knupffer2 studied the influence of food absorption on blood

1 Rev. de Med., Paris, February, 1922, 39, 91.

2 Deutsch. Arch. f. klin. Med., February 21, 1922, 138, 321.

LIVER 81

bilirubin, and found a diminution of blood bilirubin to amount to 30
per cent of the original amount.

The Use of the van den Bergh Test in the Differentiation of Obstructive
from other Types of Jaundice. J. W. McNee1 gives a short account of
the van den Bergh test, which, because of its importance, I quote
verbatim. At a recent meeting of the Association of Physicians
of Great Britain and Ireland, held in Oxford, Professor Hijmans
van den Bergh, of Groningen, gave a short account of his important
work on the presence of bile pigment (bilirubin) in the blood-
serum under normal and pathologic circumstances. In doing so,
he made reference to the test for bilirubin in serum and other
albuminous fluids which is now prominently associated with his
name. I have made use of this test in the wards and in experimental
work for some months, and the results obtained have, up to the
present, fully realized expectations. It was intended to wait until a
much larger series of observations had been carried out, but since none
of the work of van den Bergh has so far been published in English,
the writer has been asked to make some of the main facts accessible at
once, leaving the fuller account for subsequent publication. It must,
therefore, be understood that the conclusions reached in this short
paper cannot be regarded as final, unless confirmed elsewhere or by
future work on the subject.

"The first account of the work of Hijmans van den Bergh on the pres-
ence of bile pigment in serum appeared in 1913, and a full description of
his observations has been collected in a monograph entitled Die Gallen-
farbstoffe im Blute, published in 1918. More recently (June, 1921) a
short summary of the main methods and facts appeared in the Presse
Medicate.

"Confirmation of some of the chief results claimed by van den Bergh
has already been given in Germany by Lepehne (1921), and Rosenthal
and Holzer (1921).

"The clinical application of the test in the differentiation of various
types of jaundice will be dealt with here alone, although this is merely a
small part of the ground which has been covered by van den Bergh.
The important observations which are more concerned with experi-
mental work on diseases of the liver, and with the occurrence of latent
jaundice under conditions in which icterus has not hitherto been recog-
nized to exist, must be omitted. It is already certain, however, that
future research work on hepatic disorders must be greatly influenced
by the application of the knowledge made available by van den Bergh's
methods.

"The chief clinical value of the test is that by its use jaundice due to
obstruction of the main bile ducts by carcinoma, hepatic cirrhosis,
obstruction in the portal fissure, or gall stone in the common bile-duct,
can be clearly differentiated from jaundice of hemolytic origin or due to
functional derangement of the liver cells. In this latter category are
now included the various forms of hemolytic and acholuric jaundice,

1 British Medical Journal, May 6, 1922, p. 716.
6

82 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

and also functional jaundice, such as catarrhal jaundice, toxic jaundice
in infective diseases (typhoid fever, pneumonia), icterus neonatorum,
etc. It is perhaps not yet generally accepted, except by those who
have followed closely the work on hepatic disorders published in recent
years, that all modern work strengthens more and more the view that a
true hemolytic icterus, apart from the liver, does occur, and also that
"catarrhal jaundice" depends on a hepatitis with functional derange-
ment of the liver and not on an obstruction to the bile ducts. The
newer methods of van den Bergh throw further light on the question
from a new angle, and entirely support both the occurrence of a functional
icterus apart from biliary obstruction, and of a hemolytic icterus with
which the liver itself is not concerned.

"The value of van den Bergh's test in the differentiation of obstructive,
from what may be termed functional and hemolytic, jaundice is illus-
trated by a few chosen reports of cases given at the end of this short
communication.

"Mechanism and Technic of the Test. Hijmans van den Bergh began
his work faced with a difficulty which has confronted all who have worked
chemically or experimentally on the different forms of jaundice — namely,
the want of a delicate and trustworthy test for small amounts of bile
pigment in an albuminous fluid such as blood serum. The tests hitherto
employed, such as the Gmelin and Huppert tests, with their various
modifications, have many disadvantages (especially in albuminous
fluids) and are, besides, far from delicate for quantitative estimations.

Van den Bergh has applied, for his purpose, the so-called "diazo
reaction," first described by Ehrlich, who found that bilirubin, when
dissolved in chloroform or alcohol, gives with diazonium salts a reddish
color in neutral solutions and a bluish color in acid solutions. Making
use of this reaction to detect the presence of bilirubin in blood-serum,
van den Bergh and Snapper found that it gives extraordinarily delicate
and certain results. They observed, for example, that every normal
serum contains bilirubin in a dilution of from 1 to 400,000 to 1 in 250,000.
Such a dilution in human serum is readily detected by the diazo test.
They found further, after much observation, that no other substance
likely to be present will give the reaction, and they have never detected
any other substance in a human serum, except bilirubin, which has
given a positive result, Biliverdin does not react to the test. It is to
be noted also that lutein, which in certain cases (diabetes, etc.) may
deeply color human blood serum and even give the appearance of jaun-
dice to the skin, does not give the reaction.

"Technic of the Test. For the test, an ordinarily carried out, about
3 cm. of serum may be required, although less will suffice after some
practice has been obtained. The blood is taken from a vein in the usual
way into a dry test-tube, allowed to clot, and the separated serum is
then removed by a pipette. It is best to begin to practise the test on a
case of fairly intense icterus.

" Apparatus and Reagents Required:

"LA few test-tubes of ordinary size.

"2. Freshly prepared Ehrlich's diazo reagent. This consists of two

LIVER 83

solutions, each of which keeps well, but the mixture of the two must
only be made immediately prior to the test. The two solutions are made
up in the following proportions:

"A. Sulphanilic acid il00"

Concent rated hydrochloric acid 15 cc.

Distilled water 100° cc-

"B. Sodium nitrite 0.5 gram

Distilled water 100 cc.

"The diazo reagent consists of a mixture of these two solutions in the
proportion of 25 cm. of solution A to 0.75 cm. of solution B.

"3. A graduated 1 cc. pipette.

"4. Absolute alcohol (96 per cent).

"5. A centrifuge and centrifuge tubes.

"The test is then carried out as follows: To 1 cc. of the serum, in a
small test-tube, van der Bergh adds 0.25 cc. of freshly prepared diazo
reagent. (Lepehne, and the writer, have found that better results are
frequently obtained by adding 1 cc. of the reagent. One of three events
may now occur:

"1. An Immediate (Direct) Reaction. This begins instantly and is
maximal in ten to thirty seconds. The color reaction obtained is a
bluish-violet, of intensity depending on the amount of bilirubin present.

"2. A Delayed Reaction. This begins only after one to fifteen minutes,
or even longer, and consists in the development of a reddish coloration,
which gradually deepens and becomes more violet. (It will be seen
later that this reaction is not made use of further, being replaced by the
so-called indirect reaction or test — vide infra.)

"Interpretation. If the reaction is immediate or direct, an obstructive
jaundice is indicated.

"If a direct or immediate reaction is not obtained, proceed as follows:
To 1 cc. of serum add 2 cc. of 96 per cent alcohol. The mixture is
made in a centrifuge tube, which is then centrifugalized until all the
albuminious precipitate has sunk to the bottom to leave a clear yellowish
supernatant fluid. To 1 cc. of this supernatant fluid add 0.5 cc. of
alcohol and 0.25 cc. of Ehrlich's diazo reagent. (The reason for the
addition of 0.5 cc. of alcohol is to get a proper dilution for the quantita-
tive test, referred to below, and may be omitted where that test is not
being carried out.) A violet-red color is then obtained if bilirubin be
present, which is of maximal intensity almost at once.

"Where no direct reaction has been given, but a perfect indirect
reaction after alcohol precipitation, then the jaundice can be inferred to
be either hemolytic in origin or dependent on some functional derange-
ment of the liver cells without obstruction.

"It should be mentioned that all serums which give a direct reaction
will give, in addition, an indirect reaction, but the converse is not, of
course, true.

"By these two simple tests, therefore, a distinction can be drawn
between icterus due to obstruction of the main bile ducts from gall

84 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

stones, tumor, hepatic cirrhosis, etc., and an icterus of hemolytic,
infective or functional origin.

"What is the mechanism of the test, and how is it that the bilirubin
present in the serum in obstructive jaundice reacts to the diazo reagent
quite differently from the bilirubin in hemolytic, catarrhal, and other
forms of jaundice?

"It appears to depend on the fact that the bilirubin differs molecularly
in the two conditions, and, without going deeply into theoretical con-
siderations here, van den Bergh suggests that in the case of bilirubin
giving the indirect test only, the pigment has been in some way bound to
albuminoid substances in the serum, and the union is only broken down
by time or by alcoholic precipitation. The reader must be referred to
the original papers for further consideration of this point.

"Taking this short explanation for granted, the rationale of the
biphasic reaction becomes intelligible. It would appear to depend on the
presence of both types of bilirubin, in different proportions, in the same
serum. If the first variety predominates, the reaction might be
described as biphasic direct, and the other as biphasic indirect. The
occurrence of the biphasic reaction is fortunately not very common,
but, until much further experience with the test has been gained, it is
best for the moment to draw no absolute conclusion in a case giving such
a result. The writer is finding such cases of great interest at present,
and it is already evident that in, for example, cardiac valvular disease
with failure, back pressure and hepatic enlargement, the icterus which
sometimes occurs may be at first functional and later obstructive in
type as the hepatic enlargement increases, the bilirubin showing a
gradual transition through a biphasic stage with the test.

''Application of the Test for the Quantitative Estimation of Bile in
Serum. Although the simple test as described above will probably be
the first to be commonly used clinically, it is an obvious advantage to
be able to estimate the increase or decrease of bile pigment in the blood
serum, expecially in cases of obstructive jaundice. This may have
importance, for example, in cases of suspected carcinoma of the liver, or
in the recognition of the exit of a gall stone from the common bile-duct.
It is, of course, well known that the icteric tint of the skin changes
comparatively slowly. It has also an importance in the study of
various forms of "latent icterus," such as dealt with in a later com-
munication.

"The so-called indirect test of van den Bergh, which, as has been
stated, is given by all forms of icterus whether obstructive or non-
obstructive, lends itself easily to a quantitative estimation of bilirubin
by a colorimetric method. For full details of the method, the original
papers should be consulted, but the main principles may be briefly given
here. At first, van den Bergh made use of chemically pure bilirubin to
prepare a solution for comparison, but he was able soon to replace this
with an artificial standard solution giving a color suitable for com-
parison. This solution, moreover, is made up in a strength which can
give a definite reading in "units" of bilirubin. The artificial solution
consists of iron sulphocyanide dissolved in ether, in a concentration of

LIVER 85

1 in 32,000 normal. This solution is of a color which corresponds
exactly with that of azo-bilirubin (as produced in the "indirect test")
of 1 in 200,000 the quantity found to be the average amount in the
serum of a healthy individual. An indirect reaction giving a color
exactly corresponding to this standard is taken as indicative of " 1 unit"
of bilirubin.

"The Solution of Sulphocyanide. The standard solution of iron
sulphocyanide is prepared as follows:

"Dissolve 0.1508 gram of ammonium iron-alum in 50 cc. concen-
trated HC1, and add water to 250 CC. This gives dilution of 1 in 8000
normal, which will keep for about six months.

"To 3 cc. of this solution add an equal volume of 20 per-cent potas-
sium sulphocyanide and 12 cc. of ether. Shake well, and when all the
reddish color has passed into the ether transfer the ether carefully,
either into a colorimeter, or other comparative tube. This solution is
in a concentration of 1 in 32,000 normal, and must be prepared freshly
each day a test (or tests) is made.

"I have made use of the simple Autenrieth-Funk colorimeter for the
quantitative estimation, but any form of colorimeter is, of course,
applicable. For rough clinical use, dilution of the fluid obtained in the
indirect test may be made in test-tubes of equal caliber, and reasonably
accurate comparative results obtained. It should be pointed out that,
even with the complete technic of van den Bergh, the results are of an
accuracy which is adequate for clinical purposes only. There are various
fallacies which prevent a completely accurate estimation of the whole of
the bilirubin present in any serum. One of the chief of these depends
on the fact that some bile pigment is always carried down in the albumin-
ous precipitate when alcohol is added. The amount, however, is always
small, and is greater in cases of obstructive than non-obstructive icterus.

"Report of Cases. Case 1. Female. History of three rttacks of
jaundice, with vomiting and epigastric pain, within a period of a few
months. Stools clay-colored. Roentgen-ray examination showed two
shadows at the level of the twelfth rib, to the right of the middle line,
but deeply back in the body. There was doubt as to what these
shadows were — biliary calculi, renal calculi, or calcified glands. On the
clinical features of the case a diagnosis of gall stone blocking the common
bile duct was made.

"On applying the van den Bergh test, the following result was
obtained :

"Direct test Negative

Indirect test Positive (3 units of bilirubin) .

"Exploratory laparotomy was performed; the gall-bladder and bile
ducts were normal, and patent throughout. The liver was not enlarged,
but icteric in color. The diagnosis was changed to catarrhal jaundice,
and the patient made a straightforward recovery.

"Case 2. Female. This patient, a nurse in a fever hospital, had been
previously admitted for jaundice, which was said to have followed a
febrile illness of some weeks duration. Typhoid was at first suspected,

86 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

but the Widal reactions for the enteric group of fevers were negative.
The jaundice passed off, but the patient was readmitted for a second
attack, accompanied by pain in the right hypochondrium. The stools
were light colored. A diagnosis of gall stones was made.
"The results of the van den Bergh test was as follows:

"Direct test Negative

Indirect test Positive (4£ units of bilirubin).

"The abdomen was opened, but the gall-bladder and bile-ducts were
found to be normal. The patient quickly recovered, and the jaundice
passed off.

"Case 3. Female. History of several attacks of severe pain in the
right hypochondrium. Never jaundiced until one week before admis-
sion. Jaundice of moderate degree. Cholecystitis was the diagnosis
regarded as probable.

"The van den Bergh test gave the following results:

"Direct test Positive

Indirect test 4 units of bilirubin.

"At operation, the gall-bladder was found to be much contracted and
embedded in dense adhesions passing along the portal fissure. One
large stone was removed from the gall-bladder, but examination of the
common bile-duct was almost impossible owing to the dense adhesions.
A leak unfortunately occurred from the septic gall-bladder, and fatal
peritonitis followed. At the necropsy, the gall-bladder was found to
be greatly contracted and strictured. The common bile-duct was
embedded in dense adhesions, but no stones were found.

"Case 4. Male. History of jaundice of three weeks' duration ; loss of
weight; stools light colored. Nothing could be made out by palpation
of the abdomen.

The van den Bergh test resulted as follows:

"Direct test Positive

Indirect test 12 units of bilirubin.

"At operation, a carcinoma of the head of the pancreas was found
obstructing the ampulla of Vater."

The Use of Levulose as a Test for Hepatic Insufficiency. Spence and
Brett.1 This is a study in the effect of levulose on blood-sugar in sub-
normal and also pathologic cases, including several cases of salvarsan
jaundice and several other forms of liver disease. The conclusion of
these authors was that a valuable indication of the efficiency of the
liver can be obtained by estimating the changes in blood-sugar con-
centration which follow the ingestion of levulose. In healthy adults
with normal liver efficiency, a dose of 50 grams of levulose will produce
no appreciable rise in blood-sugar. In subjects with diminished liver
efficiency, a definite rise in blood-sugar will result from the ingestion

1 Lancet, December 31, 1921, 1362.

LIVER 87

of levulose. The height and length of the blood-sugar curve which
portrays this rise will be in proportion to the degree of liver inefficiency
which is present. The dose affords a means of estimating the degree
of liver damage in cases of toxic, salvarsan hepatitis and other diseases
of the liver. The kidney threshold for levnlose is lower than that for
glucose and varies in different individuals, and it is this inconstancy of
the threshold for levulose which renders the old method for testing liver
efficiency by urinary examination inaccurate.

Euriquez, Binet and Gaston Durand1 discuss gastric symptoms asso-
ciated with biliary lithiasis. They are apparently of two varieties; one
which is found immediately after the meal, and the other which occurs
six to eight hours later. The delayed type indicates reflex pyloric
cramps and often develops into paroxysmal gastric crisis. Biliary colic
of course is sudden and acute in onset.

In noting these forms of gastric manifestations, emphasis must be
placed on the general history of the patient, the antecedents of gout,
gravel, migraine, or cholemia in either the patient's history or his
antecedents. The time at which the attacks occur, their frequency,
and the condition of the bowels should also be noted. Many of these
cases show nausea in the morning and dizziness in the evening, sensations
of heaviness and even cold sweats. This sick feeling disappears after
breakfast to return later and not disappear entirely until after the
noonday meal.

Gastro-vesicular attacks are usually more painful than ulcer crises,
and there is often a slight rise in temperature and bile pigments in the
urine. The diagnosis should be made by gastric analysis, roentgen-ray
studies, and the demonstration of pericholicystitic adhesions.

Biliary lithiasis is more frequent in men than women, and these cases
are particularly susceptible to physical or nervous shocks or to a diet
rich in fats.

That the autonomic nervous system plays an important role in the
formation of many digestive syndromes is unquestioned. In many
instances these nervous phenomena have been assumed to be reflex, or
frequently hyperirritable from endocrine imbalance.

Loeper, Debray and Forestier2 discuss the role of the pneumogastric
in nervous dyspepsia. These authors found, after slight irritation of
the gastric mucous membrane of the dog, if a poison, like formol, is
injected into the stomach, the formol, when sought for by chemical
tests, can be found in the trunk of the vagus. If a toxin, like tetanus
toxin, is injected into the nerve trunk of the guinea-pig, it appears in
the central trunk of the vagus. These experiments would indicate
reabsorption of the toxins and poisons by the vagus, and it is likely that
medicaments, as well as the products of abnormal fermentation and
putrefaction, would affect these nerves in the same way. These toxic
products apparently travel to the bulb. Peptone sometimes, after
absorption, tends to localize in the bulb. These studies, as well as

1 Presse Medicale, July 9, 1921.

2 Progress Medicale, August 27, 1921.

88 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

others of a somewhat similar nature which have appeared from time to
time, are suggestive of a new field.

The Action of Various Salts and other Substances on the Liver After
Their Introduction into the Duodenum. Einhorn1 discusses the question
of the effect of various salts on the liver after the introduction of these
salts into the duodenum. He takes exception to the assumption of
Lyon that magnesium sulphate introduced into the duodenum pro-
duces a dark-colored bile which is real gall-bladder bile. Einhorn
claims that the dark bile does not appear to be the real gall-bladder
bile for the following reasons:

1. The color change following the introduction of Epsom salts is not
an abrupt one.

2. If Epsom salts produced an evacuation of gall-bladder bile, then the
same colored bile should appear when any strength of Epsom salts is
injected. This, however, is not the case according to Einhorn. The
stronger the magnesium sulphate solution, the darker the color and the
higher the specific gravity of the bile, indicating the Epsom salts has a
direct influence on the bile itself.

3. A great many other solutions such as sulphate of soda, bicarbonate
of soda, and others, have exactly the same effect on the color reaction,
which, according to this author, accounts for the effect of these ingredi-
ents on the liver.

4. After administering the magnesium sulphate test, an immediate
repetition of the test frequently provokes a reiteration of the bile
reaction with its entire series of color plays. If the dark bile were
gall-bladder bile, the reaction could not take place anew since the gall-
bladder had emptied its contents.

5. Patients whose gall-bladders have been removed will give similar
reactions after Epsom salts installation, clearly showing that the gall-
bladder of such can have nothing to do wTith the phenomena of color
changes in the bile.

The author, in this communication, used a number of substances
besides magnesium sulphate, sodium sulphate, sodium citrate, mag-
nesium citrate, bicarbonate of soda, chloride of sodium, calomel, mer-
curochrome and many other substances, and the method used was the
same as the one which he used on the previous occasion; viz., installing
a 60 cc solution of the desired salt or some other ingredient into the
duodenum at blood temperature, and the siphoning it back by gravity.
In this report are given detailed descriptions of the findings in these
cases. He, furthermore, asserts that apparently all substance? produc-
ing dark bile, do it whether the gall-bladder is present or not, and it is
therefore evident, according to this author, that the gall-bladder has
nothing to do with this phenomena. This author, furthermore, points
out the fact that at operation with the duodenal tube in place two
important points were ascertained. Magnesium sulphate, when given
through the tube, after waiting five to ten minutes showed no dark bile,
and the gall-bladder which was exposed and constantly observed, did
not show contraction.

1 New York Medical Journal, September 27, 1921, p. 262.

THE GALL BLADDER 89

From Einhorn's observations, he is of the opinion that this dark bile
comes from the liver, and reports a bile of increased concentration in
response to the introduction of substances of marked increase in con-
centration. Furthermore, Finhorn points out the fact that if one wishes
to study the bile from the gall-bladder, the best time to make the
observation is in the fasting condition and that any previous stimulation
or aspiration usually succeeds in obtaining what little bile there is in the
duodenum from the liver and the gall-bladder, and he believes that
diagnostic theory is more valuable from the fasting bile than bile
obtained by stimulation through magnesium sulphate. On the other
hand, in cases where there is likelihood of swelling of the duct a sug-
gestion such as this: viz., the increased velocity of bile through the
duets, is of value.

THE GALL-BLADDER.

The Genesis of the Gall-bladder. Broman1 discusses in a general way
the origin and function of the gall-bladder. From his studies, he
believes that the gall-bladder is nothing but a rudimentary organ, and,
in a general way, can simply be considered part of the liver. His
theory is somewhat as follows:

The gall-bladder it is believed develops from the caudal part of the
first hepatic rudiment. This part is therefore called the pars cystica.
This portion may develop simultaneously with the liver segment and
reach a very large degree of development. In fact, in some of the verte-
brate animals the gall-bladder is connected with the liver by means
of communicating tissue. In others, it is only very slightly connected
with the liver, while in man it is totally separate from the liver. Never-
theless, in certain animals it is obvious that no gall-bladder develops
under normal conditions. This is particularly the case with rats, horses
and pigeons. In these animals it cannot be assumed that the function
of the liver cell and the ensuing mechanisms of the biliary duct is very
different from those animals which have gall-bladders. In fact, many
authors are of the belief that the function of the gall-bladder is of very
little importance. Some authors speak of the gall-bladder as being
simply a modified biliary duct, and it certainly is true that in man this
organ can be removed without any very marked change in function of
the hepatic system. It must be recalled in this communication, howT-
ever, that there are many observers who believe that the gall-bladder
has a special concentrating function insofar as the storage of bile is
concerned.

Another interesting communication from Sweden is that of Lowenh-
jelm.2 He discusses the development of the biliary capillaries in rabbits.
This author observed from reconstructed models of the livers of young
and grown rabbits that the majority of liver cells turned three surfaces
toward the blood capillaries and three surfaces toward the other liver
cells. In the center of the surface between the liver cells are the bile
capillaries, which meet in a point on the surface of the liver cells.

1 Upsala lakaref. forh. Stockholm, September 1, 1921, Xo. 7, vol. 36.

2 Ibid., No. 21, vol. 36.

90 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

This paper takes up in a general way the origin of the biliary capil-
laries and would be of interest to anyone who is concerned in this
subject.

Lyon, Bartle and Ellison1 discuss the question of biliary tract disease
with some lessons learned from duodeno-biliary drainage. In this paper
the authors discuss the general question of biliary drainage and its appli-
cation to various conditions of the gall-bladder tract. This study was
an intensive one of 100 consecutive cases of gall-tract diseases in practice.
Thirty-one of these cases were studied by the roentgen ray, and 35 of
them by a careful review of the findings of previous laparotomies, 17 of
which were operations or reoperations upon the biliary tract. Twenty-
two of these cases had their appendicies removed. Ninety-four of these
100 cases were carried through a course of treatment for their condition.
These authors, in discussing the various symptom-groups which Cheney
describes in his paper on Diagnosis of Gall-bladder Disease, claimed,
regarding Group 4, in which there are no symptoms except those pro-
duced by the stomach over months and years, that it is important to
recognize this stage of precalculus formation. In other words, by
diagnosis at this stage, many cures can be accomplished therapeutically
by this method, without having later recourse to surgery. In Group 5,
which Cheney describes as a group in which the gall-bladder contains
stone, but gives rise to no symptoms of any kind until either some sudden
attack of pain, or operation performed for some other ailment reveals
cholelithiasis, the comment is made that this group can be recognized
in most instances by careful study of the chemistry and physiologic
properties, the cytology and bacteriology of the gastro-duodeno-biliary
fluids when analyzed with, and. balanced against, the evidence or data
obtained by history and physical and laboratory examinations.

In their series of 100 consecutive cases, 27 gave clean-cut gall-bladder
syndromes; 4 per cent, gall stone syndromes; and 22 per cent, of a mixed
syndromes, gall-tract, duodenum, appendix and colon, whereas 47
per cent presented only a vague atypical dyspepsia. Eighty-eight per
cent of these 47 cases showed unsuspected infection of the duodeno-
biliary zone, among which 50 per cent showed streptococcus infection.
Of these 100 cases, 32 would have been readily diagnosed as gall-tract
diseases in the light of history and physical examination, whereas,
according to the authors, 68 per cent would have failed of such diagnosis
except by a study of the characteristics of the bile. The authors point
out that the method of drainage of bile offers a means of diagnosis of
biliary diseases to supplement the usual clinical methods, and is, further-
more, an alternative method of treatment of many types of gall-bladder
and duct diseases in which there arises the question as whether surgery
is, or is not, indicated. Third, a supplementary method of postoperative
cases, continuing the surgical principles, the drainage in these cases
incompletely cured by surgical means alone.

It is not necessary, in this communication, to go into the details regard-
ing the separate collection of the various biliary samples or an explana-

1 American Journal of the Medical Sciences, January, 1922, Xo. 1, 163, 60, and
February, 1922, Xo. 2, 163, 3, 223.

THE GALL-BLADDER 91

tion of the various characteristics of the samples obtained. They point
out, from a consideration of their cases, that surgery has, in the first
place, failed in too large a percentage of eases to free the biliary tract
of infection. They point out also the fact that the probable points of
primary infection are to be found in the tonsils, gums or teeth, sinuses,
and the bronchia] trees; and the five secondary foci are the stomach, the
duodenum, the gall-bladder, the appendix and the reeto-sigmoid colon.
In the 12 cases previously operated upon, they were able to demonstrate
by cultural methods infection in 9 cases, and in 10 of these there was
pathogenic focal infection in the tonsils, teeth or sinuses. Of 84 cases,
they could classify all of them as having various degrees of cholecystitis;
they found 39 with suspicious teeth, 29 cases of infected tonsils; 18 cases
had pyorrhea; 17 cases had postnasal discharge, 3 of which were proved
sinus infection; 6 cases had chronic bronchorrhea; 4 cases had chronic
otitis media.

Regarding the question of biliary drainage in the fasting stomach,
they found that 71 per cent of cases which had been operated on showed
both fasting and digestive biliary regurgitation as against 47 per cent of
fasting and 23 per cent of digestive regurgitation in the non-operated
cases. This would seem to indicate that gall-bladder operations had
definitely destroyed the physiology of that segment of the bowel.

Regarding the bacteriologic findings, positive bacterial findings were
demonstrated in 93 cases. Of the 93, streptococcus was found in 50
per cent; the staphylococcus in 25 per cent; the colon bacillus in 15
per cent; the bacillus subtilis in 8 per cent; bacillus pyocyaneus in 1 per
cent and bacillus typhosus in 1 per cent. Fifty-six of these cases gave
evidence of a duodenitis. In 94 of these cases biliary treatment was
carried out. The duodenum was disinfected and a duodenal enema of
Ringer solution was given, reenforced when necessary with sodium
sulphate, thus sweeping out of the intestinal tract such infected bile.
The duodenal enema of 250 cc is kept at 103° F. and allowed to drop in
slowly in not less than twenty minutes. Of these cases, 73 showed a
complete arrest of symptoms; 17 showed a partial arrest, and 4 of them
were unimproved. In 47 cases it was demonstrated that there wTas a
normal return of bile, while 45 cases still showed abnormalities in bile.
The. authors then proceed to give clinical accounts of a series of cases in
which this method of treatment was carried out. These cases represent
divergent types of cases and they are well worthy of perusal.

Selman, Martland, Synnott1 discuss the question of non-surgical
biliary drainage in diabetic and hypertension cases. Of 53 diabetic and
4 other patients with whom the procedure was used, 20 had a positive
history of gastric or biliary symptoms. Of these 20 cases, 3 gave
positive results and 3 a diagnosis of suspected infection. With a special
study made of 6 cases, the first 1 had hypertension, was diabetic and
the gall-bladder had been removed in 1914; 1 had chronic pancreatitis
and 4 had frank diabetes.

1 Journal of Metabolic Research, March, 1922, 1, 357.

02 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

The authors came to the following conclusions:

1 . The negative findings in 49 out of 53 diabetic cases in the present
series support the theory that most cases of diabetes are not due to
ascending duct infections extending into the pancreas, but more probably
to previous attacks of blood-borne infections such as the acute infectious
fevers.

2. An appreciable number of patients with previous infection of
the biliary or upper abdominal region show evidence of extending infec-
tions. It is important to clear up such infections in order to eliminate
one of the main factors contributing to downward progress. In the
case of hypertension, elimination of the focus may destroy the toxic
bacterial factor which tends to maintain hypertension.

3. The Lyon method is the only non-surgical diagnostic procedure to
determine whether or not the biliary system is infected. When infection
is present, the value of this method as a mode of therapy in certain cases
of diabetes remains to be demonstrated.

Clarke and Perry1 discuss the question of gall-bladder diseases. These
individuals were not able to obtain information reliable enough by
biliary drainage to attach any extraordinary significance to it. In this
article the general findings associated with gall-bladder disease are
discussed.

Gibson2 has used biliary drainage with apparent benefit and with good
results. He says the Lyon-Meltzer technic is not difficult, but requires
time, patience, and a careful technic to secure the best results. It is
not only of diagnostic value, but therapeutic, and is worth while in all
cases associated with biliary stasis, but is of obviously little value in
cholelithiasis and chronic cholecystitis with thickening of the walls of the
gall-bladder.

Synnott3 discusses the diagnostic and therapeutic value of Lyon's
method of non-surgical biliary drainage. This author discusses, in a
general way, the technic used, and points out the fact that infection of
the gall-bladder and gall-ducts is not to be overlooked even though there
be no symptoms referable to this condition. He discusses, in a general
way, the method which is commonly employed by Lyon, and others,
and suggests that this technic should form a part of every search for
focal infections. It can be used for an accurate diagnosis of duodenitis,
choledochitis, or cholecystitis. Two typical cases are given.

Smithies, Karshner and Olcson4 discuss non-surgical drainage of the
biliary tract. In this paper, which is a complete one, these authors
attempt to reply to the criticism which has been launched against this
method. For instance, it has been claimed that magnesium sulphate
does not do anything which hydrochloric acid, salt solution, peptones,
food, water, foreign bodies, and other substances, are capable of doing.
These authors do not deny the truth of this criticism, but point out the
fact that the use of magnesium sulphate solution has certain well-

1 Virginia Medical Monthly, 1922, 49, 74.

2 Northwest Medicine, March, 1922, 21, 79.

3 American Journal of Surgery, June, 1922, 36, 136.

4 Journal of the American Medical Association, December 24, 1921.

THE GALL-BLADDER 93

defined traits. Then, again, it lias been pointed out that there was no
necessity for the direct introduction of magnesium sulphate into the
duodenum through a tube; that this solution introduced into the stomach
produces the same effect as when used in the duodenum. The authors
point out again that the haphazard fashion of introducing magnesium
sulphate in that way is very different from the method of direct applica-
tion suggested by Meltzer and Lyon. Surgeons have stated, for instance,
that the method is not of service, inasmuch as, laparotomy with a duo-
denal tube in position, the injection of magnesium sulphate solution
has not been followed by visible contraction of the gall-bladder. These
authors point out the fact that in diseased conditions of the biliary
tract, it is hardly probable that such a mechanism would occur.
Furthermore, that it is a well established observation that the general
anesthetic can be considered successful only when administered to the
point of inhibition of intestinal peristalsis and relaxation of the abdominal
muscles. These authors point out, however, the fact that it has been
shown on incompletely anesthetized individuals and on dogs whose
duodeni have been segregated, local introduction into the duodenum of
hyperisotonic solutions of magnesium sulphate, with subsequent early
withdrawal, produces a definite visible dilatation of the viscus, contrac-
tion of the gall-bladder and of the bile-ducts with outpouring of bladder
and liver bile.

Furthermore, the authors point out to those authors who claim that
the dark "B" bile is liver bile produced by the action of magnesium
sulphate on the liver, that according to the observations of Meltzer and
Auer, and also Mendel and Benedict, the magnesium salts are rarely
absorbed from the alimentary canal. The authors ask where, in the
course of the biliary passages from the ampulla of Vater to the liver, can
such accummulations of the special type of bile be held, if not in the
gall-bladder. Furthermore, it is a common observation that following
gall-bladder removal, or drainage of the gall-bladder, one may obtain a
bile which is darker in color or even mucoid. This does not flow freely
under pressure as does the "B" fraction normally. Furthermore, they
point out the well-known fact that when patients have had a chole-
cystectomy operation performed, dilatation of the common or the
hepatic ducts is frequently pronounced, accounting for a certain amount
of storage until there is a digestive demand for it.

These authors carry out their treatment, usually studying the patient
only after an absolute twelve-hour fast, with the stomach and duodenum
food-free. Sterile tubes are passed and lavage of the duodenum or
stomach may, or may not, precede the injection of the magnesium
sulphate solution. They inject the magnesium sulphate solution into
the duodenum and then withdraw the solution within three minutes
of its slow injection, which does not permit of very marked intestinal
stimulus. From one-half to practically all of the magnesium sulphate
solution can thus be recovered in the majority of instances.

In some 1500 drainages, they summarize the findings in 679 carefully
controlled attempts. In 584, or 86 per cent of sessions drainage, was
satisfactory, and failure was experienced in 94, or 13.85 per cent. The

94 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

unsatisfactory cases were due mainly to the failure of the tube to reach
the stomach, obstinate vomiting or persistent pylorus spasm. It is
interesting to observe that of 104 patients from whom any quantity of
spontaneously discharged biliary fluid was recorded, in 61.5 per cent
some degree of liver enlargement was recorded at the time of physical
examination. The time interval elapsing between the patient swallowing
the tube and the appearance of the bile containing duodenal aspirates
varies considerably. Only 1 patient gave a satisfactory response in
less than two hours. Between two and four hours was required by 67;
from four to six hours by 291; and longer than six hours by 188. In
their series of studies, they point out the fact that segmentation of bile
was practically feasible, but that of 309 cases gall-bladder bile was not
secured from 100 cases. The authors believe (1) that the non-appear-
ance of bile-stained fluid in the duodenal contents after the injection
of magnesium sulphate solution, (2) a quantity of common duct bile
greater than 25 cc in which are abnormal sediments, such as blood plus
increased cholesterin pigment, calculi, epithelium, mucus and bacteria,
(3) or an absence of gall-bladder bile following repeated magnesium
introduction, indicating some disturbance in the reflex or cystic duct, or
atony, or even disturbances of the gall-bladder, or inspissation of the
contents, or malignant adhesions; and, (4) securing of too much gall-
bladder bile in quantities greater than 75 cc, are all evidences of trouble
of the biliary tract.

It is needless to say that a thorough physologic and bacteriologic
examination of the specimens must be made. It is interesting to
note the findings in Smithies cases. Living colon bacilli were found in
75.4 per cent of cases; staphylococci, in 14.9 per cent of cases; strepto-
cocci in 52.6 per cent of cases; yeast bacilli typhus micrococci, in 4.38
per cent.

These authors point out the fact that it is a mistake to assume that
this method relieves obstructive lesions, known calculi, tumors and the
like. Unless this fact is realized, this method will fall in repute, both as
a diagnostic and a therapeutic agent. The procedure is of importance,
however, in this group of cases. Inflammation of the ducts or gall-
bladder, or even in certain infections of the liver, hepatitis of toxic origin
such as ptomain, lead or phosphorus poisoning, biliary stasis of various
forms, heart diseases, serious severe anemias, in dyspeptic storms with
recurring biliousness, in chronic rheumatoid infections where presumably
the biliary tract is involved, in fact, in all cases of biliary tract infection,
in some of the cases of atypical ulcer with bilious manifestations, in
associated gall-bladder and intestinal diseases. In those cases it is
suggested that this method may be of considerable value to relieve
stasis. They suggest frequent drainage of from three to six days apart.

Bassler, Luckett and Lutz1 discuss the question of drainage of the
biliary system and come to the following conclusions:

1. The assumption by Meltzer of the law of contrary innervation is
not proved, and these authors even doubt any specific effect on the

1 American Journal of the Medical Sciences, November, 1921, 162, 047.

THE GALL-BLADDER 95

location of the sphincter of 0<l<li and contraction of the gall-bladder

induced by magnesium sulphate solution.

2. Any one of many substances taken into the stomach or injected
into the duodenum will cause a ready flow of bile, of which a solution of
hydrochloric acid in about one-third the acidity of normal gastric juice
is the most potent for discharge of bile in large quantities and obtaining
characteristic "IV bile.

3. That the deep color of "B" bile is due to oxidation and not con-
centration from retention in the gall-bladder. This bile can be found
coming directly from the liver as a phenomena of bile secretion.

4. That the viscosity of bile does not elevate its specific gravity to any
practical extent.

5. That the margin of error in deducting from the presence of muco-
purulent flakes, pus cells, inflammatory debris, bacteria and cells in the
aspirated bile as positively coming from the gall-bladder is too great for
clinical deduction.

6. That the physiology of the gall-bladder should not be deduced
from anatomy and relationship alone; that its most important function
seems to be to relieve pressure within the biliary system, to protect the
pancreas rather than acting as a reservoir for bile in a digestive sense,
and that the physiology of bile secretion and gall-bladder function should
be studied more thoroughly.

7. That cholectomized individuals show the characteristic "B" bile
even shortly after operation, before the ducts have had a chance to
dilate. This occurs so commonly that "B" biles cannot always be from
the gall-bladder.

8. The increase in specific gravity in aspirated bile, by this method,
is due to the content of magnesium sulphate which appears to be re-
absorbed into the portal circulation and is excreted by the liver sub-
stance in the bile. It is erroneous to deduce clinically in both amount of
biles obtained by any gradation (ABC D), or by specific gravity
estimations as to whether bile stasis exists or not.

9. That where true pathology exists in the gall-bladder, the method
is a poor substitute for proper surgery. It may be employed in suitable
cases as a temporary means, but it should not be depended upon to
correct or definitely benefit pathologically diseased gall-bladders or
when gall stone exists.

In a certain article in the New York Medical Journal, March 1 and
April, 1922, Lyon replies to certain antagonistic criticism of the method
of biliary drainage. He points out the fact that Brown, Smithies,
Wipple, Simon, Sachs, Friedenwald, Synnott, Levin, Niles, White, and
others, have confirmed the soundness of the principle on which this
method of treatment and diagnosis rests. On the other hand, certain
writers, Einhorn, Crohn and associates, Dunn and Connell, Bassler, and
others, as the result of their experimental observations, have attacked
the very roots of the method which he proposes to answer.

Regarding the idea that many substances can give rise to this form
of stimulation, and that magnesium sulphate is not alone in this property,
he points out the fact that he had never contended that this was the case,

96 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

but was of the opinion that magnesium sulphate had the greatest power
to relax the duodenal wall, and then came peptone, and, finally, hydro-
chloric acid. Regarding Einhorn's statement, Lyon replies to that In-
stating that the abrupt transition is hardly to be expected, but may
occur, dependent largely upon the question of the intactness of the
gall-bladder and duct musculature and its tonus. Regarding the
assumption of Einhorn that the stronger the mixture of magnesium
sulphate, the darker the color of the bile, he mentions the fact that this
is entirely within keeping with the theory that weaker solutions will not
deliver as much dark colored bile as the stronger solutions. He further-
more acknowledges that many solutions, such as sodium sulphate,
bicarbonate of soda, and other chemicals, act in a similar manner, but
do not influence the gall-bladder musculature to the same extent.
Regarding the sequence of the dark bile to follow the reintroduction of
Epsom salts, he points out the fact that this view is fallacious, and also
mentions that it is possible for such a sequence to take place in the
presence of atony of the gall-bladder, or partial obstruction of the cystic-
duct. Regarding the question of dark colored bile in cholecystectomized
cases, Lyon has seen few cases in which there was a real dark colored
bile. In fact, the bile is rather of a different tint, and more often this
phenomena occurs where there is dilatation of the ducts or even the
formation of a definite diverticulum.

Regarding the question of Einhorn's work, he notices the Einhorn
reports his bile as alkaline, where as the bile is usually acid in reaction.
Furthermore, Fitts, of the Mayo Clinic, has pointed out that gall-
bladder bile has a higher acidity than bile from any other portion of the
tract. They reply to the paper of Crohn regarding, first, the demon-
stration of a functionating sphincter at the mouth of a common bile-duct.
He believes that this is clearly demonstrated, even from Crohn's own
experiments, certainly the demonstration of the contrary nervous
mechanism evolving the gall-bladder and ampulla; and this the author
explains by the fact that anesthesia is supposed to effectually blot out all
reflexes, although in one case Sax apparently succeeded in successfully
visualizing the gall-bladder evacuation when all others failed. As to
the specific effect of magnesium sulphate, Lyon goes on record as saying
that magnesium sulphate possesses some properties not possessed by
peptone, or the other chemicals tried, which favors the evacuation of the
gall-baldder contents if in no other way than by lowering duct pressure.
The author criticizes the method which Crohn uses in the carrying out
of his test. Crohn, for instance, questions the significance of cholesten »1
crystals found in the bile, but the author is of the opinion that these
crystals indicate either calculus or precalculus formation. The question
of the evidence that "B" bile is gall-bladder bile, and also evidence to
prove that the careful microscopic and chemical examinations of the
biles are of great diagnostic importance is presented both ways; and the
author clearly exposes his platform regarding the whole situation.

His reply to Bassler's criticism is again the fact that in those cases
which were examined at operation, there was a blunting of the reflexes
due to anesthesia. The author criticizes both the method of Bassler

THE CALL BLADDER 97

and Crohn and acknowledges that in its broad aspects Meltzer's law of

contrary innervation is not definitely proven, but denies, however, the
fact that Bassler has presented any evidence which would throw doubt
upon the specific effect of magnesium sulphate. In this paper, he also
denies the fact that the bile obtained with hydrochloric acid is similar
to the gall-bladder type of bile which is obtained with Epsom salts.
He, furthermore, denies the fact that "B" bile is obtained from indi-
viduals who have had a cholecystectomy performed.

The reviewer hesitates to express an opinion regarding this latter
controversy, inasmuch as he believes that the last word has not been
said regarding the significance of the types of bile obtained by duodenal
intubation. He has performed a method of duodenal intubation for
more than seven years and has done many thousands of biliary drainages.
He follows the same method of examination of the bile today that he
employed several years ago, and that is careful study of the micro-
scopic and chemical appearance of the bile, together with careful
culture of the material obtained. Where possible, any evidence indica-
ting the localization of the lesion is naturally taken into consideration.
He believes that Lyon's work has at least stimulated great interest in
the question of duodenal and biliary diagnosis, and feels that it is almost
too soon to form a tentative conclusion regarding the importance of this
method of diagnosis.

Regarding biliary drainage and treatment, he has used this method
over this period of time with great variety of conditions and expects
sometime to report of his findings. There is no question but that this
method of treatment has its field of usefulness. He uses a Murphy drip
in the duodenum with a drip of the various substances calculated to
produce results. For years, the reviewer used a combination of sodium
bicarbonate, sulphate and phosphate, and performed transduodenal
lavage, a method wThich, from its therapeutic results, he has not seen fit
to change. On the other hand, however, we are satisfied that duodenal
intubation and the examination of the duodenal fluids is a method of
procedure which cannot safely be ignored.

Tenney and Patterson1 discuss the question of the injection of bile-
ducts with bismuth paste. (1) In the case reported, that of a laborer, age
forty-eight years, the bile-ducts of the human liver were apparently
injected and the patient recovered without apparent damage. (2)
Magnesium sulphate did not increase the flow of bile, nor did it increase
in color or constancy. The magnesium sulphate acts only as a stimulant
to contractions of the gall-bladder and causes dilatation of the ampulla
of Vater, and not as a direct stimulant to the liver except as the bile in
the duodenum increases it. (3) The greatest quantity of bile wTas
secreted during the third and fourth hours after meals. (4) Psychic
tests showed no immediate change in the flow of bile. (5) One may get
normal liver bile by the use of the duodenal tube for diagnostic purposes,
even when the patient has a markedly diseased gall-bladder. (6) The
entrance of bile into the duodenum definitely increases the flow of bile

1 Journal of the American Medical Association, January 21, 1922, No. 3, 78.

98 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

from the liver. (7) Magnesium sulphate injected into the duodenum
which had no connection with the liver did not increase the flow of bile.
(8) Bile injected under the same conditions did increase the flow of bile.
Kallen1 discusses the question of the barium meal in gall-bladder
diseases. This author points out the extremely important findings
which the roentgen ray can give toward gall-bladder diseases, and
mentions the following points as evidence of a chronic inflammation of
the gall-bladder:

1. Pressure defect of the superior margin of the duodenal bulb.
Formerly this was supposed to be entirely due to the gall-bladder.
Today we know it can be due to the liver as well, and is constant because
of the fixation of the duodenum and the gall-bladder or liver, or both.

2. Adhesion deformity of the superior margin of the duodenal bulb.
This is recognized by the loss of the smooth outline and the jagged
irregularity which replaces it.

3. Permanent alteration in the position of the duodenal bulb. This
is recognized by a displacement of the duodenum from its axis, displaced
usually to the right or downward, or to the left.

4. Adhesive defect of the second and third parts of the duodenum
with loss of the symmetrical valve markings, and their replacement by a
constant unsymmetrical outline.

5. Permanent alteration in the position of the second and third
portions producing, not infrequently, acute angulation, or even left-
sided displacement back of the pylorus.

6. Delay in the second and third parts of the duodenum, best seen
fluoroscopically.

7. Defects of the lesser curvature of the stomach near the pylorus
which are not due to ulcer or cancer owing to the fact that it is not clean-
cut and punched-out and finger-like in appearance as in the later con-
dition.

8. Chronic contraction of the pyloric antrum, a condition not infre-
quently seen in this condition.

9. Displacement of the pyloric antrum, usually to the right and up,
as though it were folded back toward the lesser curvature.

10. Gross deformities of the fundus of the stomach due to bands
or adhesions.

11. Adhesive defects of the upper jejunum with loss of symmetry
of the valve markings and reduction in caliber of the area effected, and
an irregular outline of one or both margins.

12. Pronounced alteration in the coils of the jejunum.

13. Delay in the jejunum both fluoroscopically and radiographically.

14. Tenderness in the gall-bladder region.

15. The characteristic picture and gall-stone shadows, which must
be differentiated from right renal calculus, and enlargement of the
mesenteric glands, or even the contents of the colon.

16. Shadows of physiologic gall-bladders of doubtful significance. This
is difficult to determine and must be done with extreme care.

1 Northwestern Medicine, June, 1922, No. G, 21, 172.

PANCREAS 99

17. Angulation of the colon immediately beyond the hepatic flexure
is not uncommon.

IS. Dilatation of the ascending colon needs no explanation. This is
usually associated with considerable stasis.

19. Pericolic membranes at or near the hepatic flexure.

20. Pericolic membranes of the entire transverse colon.

We consider this article an extremely good one, inasmuch as it reports
in a satisfactory fashion pretty nearly all of the conditions which are
encountered in diseases of the gall-bladder. Particularly would we
point out the importance of the secondary findings in gall-bladder
disease. These secondary findings are : Cardiospasm, reflex pylorospasm,
mechanical obstruction at the pylorus or duodenum, reflex spastic colitis,
all of which are frequently associated with gall-bladder manifestations.
The author points out the importance of and the desirability of a
thorough search for the primary focal infection.

The writer also mentions the studies of Aschoff regarding the arrange-
ment of the mucous membrane and the magenstrasse as possible causes
for the general arrangement of ulcer.

PANCREAS.

Syphilis of the Pancreas. Wile1 discussing visceral syphilis mentions
syphilis of the pancreas, which, while not uncommon in the new born,
in the acquired form is one of the rarest of syphilitic visceral lesions.
From a pathologic standpoint, Warthin believes that chronic interstitial
pancreatitis is one of the most frequent visceral lesions found in latent
syphilis. The condition may occur either as a gummatous pancreatitis
or an interstitial pancreatitis, or a combination of the two. The
symptoms are not pathognomonic, but jaundice without other cause,
glycosuria, and pancreatic tumor without cachexia, are suggestive.
The therapeutic test is the most efficient diagnostic aid.

Pancreatitis Following Mumps : Report of a Case with Operation. The
occurrence of pancreatitis of mumps has been reported many times, but
Farnam2 is the authority for the statement that in only one instance
was there an autopsy reported to furnish objective evidence of the
disease. Many works on medicine do not mention the association of
pancreatitis with mumps. The possibility of simultaneous involvement
of these two glands, the parotid and the pancreas, has been commented
upon by many observers.

In 56 reports the number of days between the onset of parotiditis and
abdominal symptoms is given. In 28, the interval was from four to
seven days; in 10 cases it was less than four days; in 4 cases it was two
weeks. Males are more prone than females. The sex mentioned 99
times showed 81 males and 18 females The age incidence of 58 cases
was at least eighteen years of age, and 31 are mentioned as children.
The duration of the attack is usually short, in many instances the
authors imply that the attack lasted twenty-four to forty-eight hours.

1 Archives of Dermatology and Syphiligology, 1921, 3, 117-122.
'-' American Journal of the Medical Sciences, 1921, p. 859.

100 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

The longest duration was twenty-five days, and apparently all but the
patient of Lemoine and Lapasset (an Algerian soldier) recovered. This
was the case which came to autopsy.

Epigastric pain and tenderness are the symptoms given. The pain
may be so intense as to necessitate morphine, and is usually accompanied
by nausea and vomiting. Diarrhea is not as frequent apparently as the
text-books of medicine would lead us to believe, but 13 out of 30 accounts
of the intestinal function mention diarrhea and 10 were constipated.
A mass in the epigastrium was only felt 13 times. There is usually a
slight rise in temperature. Sugar was only found in 2 cases out of 23
in which it was sought. Acetone and diacetic acid were found 4 times,
each time associated with severe vomiting.

A summary of the 119 cases collected reveals the following generaliza-
tions: An acute abdominal condition. Probably pancreatitis is some-
times associated with epidemic parotiditis. It occurs more often in
boys and young men than other classes of the population; it usually
follows, but may precede, the parotiditis. It is characterized by intense
epigastric pain, often vomiting, occasional diarrhea or constipation
and a slight rise in temperature. A mass may sometimes be felt in the
epigastrium. It usually runs a short, benign course and has not been
shown to affect the internal secretion of the pancreas.

The author describes a case of a young Italian, aged twenty years.
Operation disclosed acute pancreatitis, and culture showed the Strepto-
coccus viridans. The patient left the hospital in good condition.

Tumors of the Pancreas. According to Lockwood,1 primary tumors
of the pancreas are rare. Cysts, carcinomas, adenomas, sarcomas and
limpomas are found in the order mentioned. Of the solid tumors,
carcinoma is the most frequent and sarcoma the least, while primary
sarcoma is rare.

This paper discusses the diagnosis of tumors of the pancreas, and also
presents a case of sarcoma of the pancreas. In discussing the question
of diagnosis of tumors of the pancreas, the author mentions the diffi-
culties encountered, and names the following symptoms as common
to all tumors of the pancreas: (1) Pressure symptoms exerted by the
tumor upon surrounding structures. The close proximity of the
pancreas to the large vessels posteriorly, and its intimate relation to the
liver, stomach, duodenum, spleen and kidney, give rise to a complexity
of symptoms often difficult to interpret. By pressure on the large
vessels, they may occasion edema or ascites, and, by pressure on the
common duct, persistent jaundice. Pressure on the renal veins is
reported by Ransohoff to produce marked hematuria. Pressure on the
stomach and duodenum often causes distension and filling defects,
simulating a tumor of the stomach on the roentgenogram.

In the reviewer's experience, this concave deformity in the contour of
the gastric image is one of the most important points in the diagnosis
of tumor. (1) Pressure on the solar plexus gives epigastric pain. Tumors
of the tail give fewer pressure-symptoms, owing to greater room for

1 Journal of the American Medical Association, November 12, 1921, No. 20, 77,
1554.

APPENDICITIS 101

expansion, and may simulate tumors of the spleen or kidney. (2)

Fatty stools, due to pressure on, or closure of, the external pancreatic
duet. This disturbance may he noted not only by the character of the
stool, which shows large amounts of unsplit fat, but also many undigested
meat fibers. Other tests of external pancreatis function demonstrate
the same defect. (3) Sugar in the urine has been reported infrequently.
(4) One of the most characteristic findings is rapid emaciation, with
cachexia and weakness.

A description of a sarcoma of the tail of the pancreas is given, together
with the history, roentgen-ray studies and operative findings of the case.
This tumor made a large defect in the image of the stomach on the
roentgen-ray plate.

Roentgen-ray Studies in Pancreatic Disease are discussed by Herren-
heiser.1 The examination of pancreatic disease up to the present is
mainly confined to indirect evidence, although pancreatic calculi give a
good picture, inasmuch as they are mainly calcium concretions. Tumors
of the pancreas are determined largely by compression and displacement
of adjacent organs.

The author discusses four types observed : (1) Changes in the middle
portion of the stomach, which are caused by tumors in the body or tail
of the pancreas and also in the left portion of the head. These changes
are usually of the lesser, and not the greater, curvature, and rarely in the
central part of the gastric image. They may be due to indentation of the
lesser curvature, in which case a differential diagnosis is necessary
between intra- and extragastric lesions; and second if extragastric,
whether pancreatic or some other organ. Furthermore, we have com-
pression of the greater curvature which is showm on the fluoroscope, and
by palpatory procedures under the fluoroscope, as well as pneumo-
peritoneum. Pancreatic tumors which are covered by the posterior
wall of the stomach may produce the same roentgenologic signs as a
tumor of the anterior or posterior wall of the stomach. The pyloric
portion of the stomach is caused by tumors or deeply placed cysts of the
head of the pancreas. Alteration of the duodenum is not infrequently
noted with carcinoma of the head of the pancreas. Even the colon
may be depressed and narrowed in its transverse portion by tumors of
the' under surface of the pancreas. Gas abscesses of the pancreas may
be detected by demonstrating an accumulation of gas in the middle
part of the epigastrium, superimposed over a level of liquid, and have no
relation to the stomach. But inflammations of the pancreas which do
not alter its contour, or produce pressure manifestations on adjacent
organs, are difficult, or impossible, to detect.

APPENDICITIS.

Laroche, Brodin and Ronneaux2 discuss the question of chronic
appendicitis and the importance of roentgen-ray examination for chronic
appendicitis. It is pointed out that many of the commonly accepted

1 Med. Klin., Vienna, February 23, 1922, 18, 229.

2 Presse Medicale, Paris, April 18, 1922, 30, 297.

102 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

physical signs of appendicitis are not sufficient to justify the diagnosis
of chronic inflammation of this organ. Pain is the important symptom,
but inasmuch as pain depends upon the position of the appendix, and
that is sufficiently variable, it follows that pain will be markedly
different. It is likewise somewhat difficult at times to make a dif-
ferential diagnosis between appendicitis and right-sided salpingo-
oophoritis. The appendix and ovaries may be in contact, making this
more difficult, so that chronic inflammation of the appendix can be
associated with exacerbations during the period. Furthermore, pain
along the course of the right ureter is liable at times to give difficulty.
It therefore follows that roentgen-ray examination of the organ is of
value, but one cannot draw conclusions regarding the appendix from its
visibility alone. The most important method of examination should be a
fluoroscopic examination combined with palpation, which will give valuable
evidence as to the position of the painful point, the mobility of the cecum
and the appendiceal region and also the association of the tender point
with the appendix. It is only when the painful point follows the change
in position of the organ that it is possible to say definitely that these
two are due to the same condition. A painful point, at the root of the
appendix or in the neighborhood of the iliocecal valves, which moves
when one moves the large bowel is one of the most satisfactory signs of
chronic appendicitis. When, however, this painful point remains in one
position, and the bowel and appendix can be moved without altering
the position of the point, one must think of trouble in the pelvis. Other
painful points that are to be remembered are those due to the omentum
and the sympathetic nervous system.

Waitzfelder1 discusses the question of the demonstration of chronic
appendicitis with the roentgen ray. In this paper mention is made of
the demonstration of fecal concretions in the appendix which can be
demonstrated by the roentgen ray. Stretching or kinking of the
appendix points also to a chronic inflammation.

The best time to examine the appendix with the roentgen ray is from
six to eight hours after the ingestion of an opaque meal, and it is pointed
out that if the appendix becomes rigid during digestion without change
in form or position, that finding is another sign of appendiceal inflam-
mation.

Jamieson2 discusses the acute appendix. In this condition, naturally
it is extremely important to make an early diagnosis. The pain is
usually colicy and intermittent, almost always at first situated in the
epigastrium or just above the umbilicus and reaches its height in from
four to ten hours. Later it radiates down to the lower right quadrant
of the abdomen and then, finally, remains in this position. By the
third day pain may have subsided, indicating a lessening of the process ;
or it may become more severe, indicating a spreading peritonitis. In
any event, in almost every case there is right-sided tenderness. There
may be a slight temperature ; nausea and vomiting may also occur. There
is usually an increase in leukocytes due to the absorption of poisons, but

1 Med. Klin., Vienna, March 2, 1922, 18, 281.

2 Canadian Medical Association Journal, April, 1922, 12, 232.

APPENDICITIS 103

an important point is the question of the types of leukocyte count.
A stationary leukocyte count with an increased polymorphonuclear
count points to gangrene. Physical examination demonstrates the
presence of swelling, tenderness, muscular rigidity, whether or not these
phenomena are localized or general, and also the extent of tenderness.
( Mien extension of the right leg will produce some pain over McBurney's
point. It is always desirable in these cases to make a rectal examination
and nothing should be left undone.

Stinsur1 discusses the treatment of acute appendicitis. Naturally,
mention is made of the two methods by which this disease is handled,
that of operation, and that of watchful waiting and careful medical
treatment. Everyone is agreed on immediate operation in the gan-
grenous and perforating form of appendicitis.

One observer summarizes the indications for immediate operation
as follows: (1) Ice is not effective; (2) vomiting is persistent; (3) the
temperature rises; (4) there is localized pain, and the abdomen instead
of remaining flaccid, contracts and also becomes distended.

If medical treatment is employed at all, starvation should be com-
menced at once and should be complete. The lips and tongue may be
moistened, but no water should be swallowed, and the Murphy drip
may be used if necessary. Ice application should be sufficiently large
to cover the entire intestinal tract so as to inhibit peristalsis. Morphine
is given simply to relieve pain, although there is a great difference of
opinion regarding the use of this substance.

Guillard2 discusses more deceptive forms of appeyulicitis. This article
deals mostly with the association of the appendix to the menopause.
The facts are based on the study of 8 cases followed in the course of the
last three years, and simply emphasize the contingencies that may arise
between the diagnosis of appendicitis and the physiologic disturbance
of the menopause. There is no question, however, that the fact that a
woman is at the critical age does not exclude the possibility of appendi-
citis, but it is likely that there are individuals who show appendiceal
symptoms which cease completely when the menopause is fully estab-
lished. There seems to be some confusion regarding this condition and
it is simply to be borne in mind as a possibility.

Bogart and Cheney3 discuss the diagnosis of chronic appendicitis.
All these cases may be divided into two groups; the first group in which
there has been a previous acute attack; and another group in which
there has been no history of abdominal pain on the right side. In fact,
one observer divides chronic appendicitis into a still larger number of
groups: (1) those associated with acute attacks extending back for
several years; (2) those associated with vague symptoms but not neces-
sarily those of acute appendicitis; (3) subacute attacks, with pain down
the right leg, urinary symptoms, but not typical outbreaks; (4) chronic
appendicitis; (5) involvement of the appendix as a part of a generalized
chronic inflammation of the whole lower part of the abdomen.

i Rev. Med. Cubana, Havana, May, 1922, 33, 388.

2 Red. Med. de la Suisse Roma, Geneva, March, 1922, 42, 9.

3 Journal of the Tennessee State Medical Association, March, 1922, 14, 411.

104 REHFUSS: DIG EST IV E TRACT AND ALLIED ORGANS

In a group of 71 cases, mention is made of 31 belonging to that group
in which the chief symptoms were those affecting the stomach. Some
were suggestive of ulcer and had a reflex hyperacidity. Others resembled
a chronic inflammation of the stomach with subacidity and spasm of the
pylorus. Roentgen-ray examination is undoubtedly of great value in
differentiating ulcer of the stomach and duodenum from chronic ap-
pendicitis. One should also bear in mind rare conditions, such as
epigastric hernia, incipient femoral hernia, an early psoas abscess, diver-
ticulitis, aneurysm of the abdominal aorta, gastric crisis of tabes, and
early malignancy of the appendix.

Guerra1 discusses the question of focal infection and appendicitis.
The appendix is an organ which is particularly well adapted to localiza-
tion of a general infection. Inflammation of the appendix frequently
occurs in the course of acute infection, and the explanation of an acute
appendicitis occurring in apparently normal individuals would suggest
the localization of a focal infection in the appendix. Inasmuch as the
appendix is an organ with deficient circulation, largely made up of
lymphoid tissue and extremely sensitive to the action of bacteria, it is
not difficult to realize that a focal infection elsewhere in the body might
readily localize in the appendix. The tonsils are probably the principle
seat of primary infection. This idea naturally is an old one, and the
question of hematogenous infection of the appendix, particularly the
acute varieties of inflammation, is one which has received recognition
from many observers.

Bloch2 discusses the vagaries associated with appendicitis. One thing
is clear — appendicitis is not always associated with the same history
and the same findings, and there is no one symptom which is infallible
in the diagnosis of appendicitis. The diagnosis should always be made
by an association of the complete clinical picture and the laboratory
tests. It must be borne in mind that many conditions are liable to
produce pain in the right lower quadrant of the abdomen, movable
kidney, ureteral and renal manifestations. Not infrequently a high
pain is due to a retrocecal appendix. Pneumonia can give rise to the
same type of abdominal pain, and in every instance in which there is
no rise in temperature, but in which the fulminating symptoms are out
of proportion to the physical signs, one must test the knee jerks and
rule out the possibility of tabes.

Adjacierno3 discusses the symptom of pain in the diagnosis of appendi-
citis. It is generally admitted that the most important point in the
diagnosis of appendicitis is the symptom pain. Furthermore, the
general debut of this symptom is in the epigastrium, and, finally, at a
subsequent period, localizes in the lower right quadrant. In many
instances, however, this symptom is only found on pressure either on
McBurney's point or Munro's point, although the structure most
frequently found under these points is not the appendix, but the ileocecal
valve. The appendix, or at least the base of the appendix, in the living

1 Cron. Med. Chir. de la Havana, January, 1922, p. 172.

2 International Journal of Surgery, March, 1922, 35, 82.

3 New York Medical Journal, June 7, 1922, p. 663.

APPENDICITIS 105

subject is on an average 2.2 cm. below the valve. Pain in the right iliac-
fossa in appendicitis may be shown in other ways: By inflation of the

colon with air (Bastedo's sign); by rectal palpation; by gentle pressure
on McBurney's point; when the patient lying horizontally raises his
right leg, causing the corresponding psoas muscle to contract and force
the painful appendix up against the palpating fingers; by traction on the
right spermatic cord; by pressure over the descending colon, proceeding
in an upward direction so as to produce an antiperistaltic wave, or
gaseous distention which even will produce severe pain in the right iliac
fossa (Kovsing' sign); or, finally, by pressing a little below McBurney's
point while the patient is turned on the left side, in which position the
swollen and inflamed appendix drops down and pulls on the mesentery
which is usually hypersensitive in such cases. Nevertheless, it can be
stated that the symptom pain in the right iliac fossa, often in the great
majority of cases of appendicitis, is not a constant one, being absent in
particularly all cases of chronic, latent appendicitis or appendicitis with
referred symptoms, such as the dyspepsia type of appendicitis, juxta-
cecalis duplivelita, where the diseased organ is completely matted to the
external wall of the cecum and concealed by the visceral peritoneum
covered by another thin membrane layer, or the so-called veiled
appendix. Toxic appendicitis is, however, a variety in which the general
phenomena of intoxication, with even severe diarrhea and albuminuria,
may occur. In this group of conditions the symptom of pain may be
latent or concealed.

As a rule, however, in all acute cases the initial symptoms are paroxys-
mal or cramp-like in character, and referred to the epigastrium or to the
mesogastric region, almost always accompanied by nausea and vomiting
and followed by pain, rigidity and tenderness in the right iliac fossa,
and rise in temperature and increase in the number of leukocytes. The
pain and tenderness usually became apparent in the right iliac fossa as
soon as the diffuse initial pain subsides. In children, however, the
epigastric signs overshadow the lower right-sided pain, and are usually
rapidly followed by symptoms of general peritonitis. In many forms of
chronic appendicitis, however, recurrent symptoms are often in the
stomach rather than in the lower right side. On the other hand, the
mere symptom pain in the lowrer right quadrant is not sufficient evidence
of the existence of an appendicitis.

While the author gives a differential chart of over one hundred condi-
tions which may simulate appendicitis, the important conditions which
ought to be borne in mind are as follows: A right floating kidney; mova-
ble cecum ; ileocecal tuberculosis ; adenitis of mesenteric glands, especially
tuberculosis; actinomycosis; acute suppurative periostitis of the inner
surface of the ilium; tabetic crisis; anginoid pains due to sclerosis of the
upper mesenteric artery. Furthermore, there are a number of cases
characteristic of transient tenderness and pain in the appendiceal region,
and by absence of other signs or symptoms of a true appendicitis, usually
occur sometime in the course of some infectious disease, such as acute
rheumatism and tonsillitis or mineral poisonings (saturnism), or primary
anemias, or anaphylactic disturbances, such as those associated with

106 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

urticaria, eczema and serum diseases. There is undoubtedly in these
cases toxic substances in the blood which stimulate the nerves going
to the appendix. For this group the author suggests the term appendi-
codynia.

This article is given over to a consideration of many of the different
forms of appendicitis which are encountered, and is well worthy of
perusal as a rather concise exposition of the subject.

Struthers reported several cases of transient acute lymphadenitis
associated with pain, swelling and tenderness which might simulate
appendicitis. Cases are mentioned in which this mistake resulted in
operation and the removal of apparently normal appendix.

Cecocolic Lesions in Chronic Appendicitis. An abnormal mobile
cecum is not infrequently associated with appendicitis of the chronic
variety. Chalier1 found this condition in 80 per cent of cases in women
and 75 per cent of cases among men. It is frequently accompanied by
adhesion formation, perityphilitis and ascending pericolitis. In such
cases appendectomy should be accompanied by fixation of the cecum.
The articles deals with the appropriate surgery for this condition.

Ulcerative Colitis. Martini and Udaondo2 discuss the important question
of ulcerative colitis. Regarding the cause of the condition, there are
many different predisposing factors, among which are chills, excessive or
faulty hygiene and diet, as well as the ingestion of contaminated food-
stuffs, malformation of the colon as in its mesentery, the situation of the
sigmoid flexure and the existence of abnormal colon ligaments, diverticuli
as well as traumatism and infection of the mucosa are all important.
The most important single activating cause is constipation. Not in-
frequently, determining causes are toxic poisoning of various kinds from
mechanical poisons; mercury, arsenic, and from the poison adulterated
bismuth. Among parasites may be included amoeba of dysentery;
among worms, the ascaris trichocephalus, ankylostoma, taenia, bothrio-
cephalus and fungi, monilia enterica, spirilla and aspergillus. Syphilitic,
tuberculous, neoplastic, and gonococcal ulcers may be found.

Regarding the symptomatology of this condition, there is practically
always some form of diarrhea present, usually with the presence of
pus and blood in the movements. The average number of movements
is from four to ten a day. There is not infrequently rectal tenesmus in
acute cases. There may be a rise in temperature, general weakness and
excessive swelling and tenderness of the abdomen, and profuse diarrhea.
In the chronic forms this is not usually so pronounced, but there is
diarrhea, a sensitive colon, often palpable, and periodic acute exacerba-
tions. Proctoscopy reveals ulcers accompanied frequently by mucopus,
and the roentgen ray of the colon confirms the diagnosis. Almost
always there is spasm on the left side of the colon. This condition
most frequently affects the terminal portion of the recto-sigmoidal
portion of the colon, inducing tenesmus and painful defecation. Occa-
sionally, there is a diffuse ulcerative colitis. Complications include
hemorrhage, peritonitis, skin eruptions, not infrequently focal infections

1 Bull, et mem. soc. de Chir. de Paris, April 4, 1922, 48, 486.

2 Review Assoc. Med., Argentina, Buenos Aires, December, 1921, 34, 465.

THE INTESTINES 107

elsewhere, venous thrombus, and even fatal endocarditis have been
noted.

Briefly enumerated, the following are the methods of treatment which
have been suggested: Restricted diet, systematic disinfection of the
bowel if diarrhea is excessive. Adrenal serum and glucose serum can
be given drop by drop, or even urotropin serum. Colon lavage with
isotonic solutions of sodium chloride, tannic acid, calcium chloride,
silver nitrate, hydrogen peroxide, permanganate of potash, methylene
blue and magnesium chloride may be used. In the curative treatment,
the most important thing is vaccine therapy. Mixed emulsions of the
colon bacillus, bacillus aerogenes, streptococcus and the paracolon
bacillus have been used with success. Vaccine therapy must be used
with care, or in fact altogether discontinued if there is hepatic, renal or
cardiac disease, and should not be given in syphilitic and tuberculous
diseases and new growth.

Surgical treatment includes appendicostomy, enterostomy, colostomy,
partial or total resection of the colon, enteranastomosis, and iliosig-
moidostomy with or without exclusion of the colon.

THE INTESTINES.

Colon. Peristalsis of the Colon. Hickey1 discusses the question
of colon peristalsis and recommends the following procedure for the
observation of colon peristalsis. The colon is first thoroughly cleansed,
either with an enema or with a laxative; then it is filled with the usual
barium enema by means of a rectal tube. It is desirable to fill the colon
to a moderate degree of distention. The rubber tube is then lowered into
a pail so that the material can return into the lower pail, and the colon
is studied by means of the fluoroscopic screen. Watched in this way
the colon becomes the seat of active peristaltic contraction. The
rectum is first emptied and then the sigmoid, and, finally, part of the
transverse colon, the beginning of this peristaltic wave being to the
right of the midline. Antiperistalsis ceases at this point.

This procedure is of value in diagnosis, and the author points out the
fact that, in some of these cases when symptoms persist in the lower right
quadrant after the removal of the appendix, it is to be noted that
peristaltic waves in the cecum start, not at the tip of the cecum as they
do normally, but in the upper portion, the lower part of the cecum being
apparently, for the time, inactive. In some cases where it is difficult to
have peristalsis owing to atony of the colon, massage may be necessary
to stimulate peristalsis.

Loeper and Bauman2 discuss the action of pepsin on the motor function
of the large intestine. Pepsin stimulates intestinal peristalsis and the
muscle tone of the bowel, and it is to be remarked that this stimulation
occurs particularly on the right side of the colon, although the drug has
little or no value as a laxative, in some cases of spastic constipation

1 American Journal of Roentgenology, April, 1922, 9, 260.

2 Bull, et mem. Soc. Med. d. hop. de Paris, May 11, 1922, 38, 726.

108 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

even aggravating the condition. It is interesting to note, however,
that the action of this substance is principally high colonic.

Donaldson1 discusses the relationship of constipation to intestinal
intoxication.

Within recent years a great deal of attention has been given to the
question of autointoxication and an exaggerated degree of emphasis
has been laid upon the liability of severe toxemia from fecal retention
over the normal period of time. Donaldson is of the opinion that symp-
toms presented by those who seek relief from constipation cannot be
taken as unquestioned evidence of the absorption of toxins; in cases of
ordinary constipation, toxins are not necessarily absorbed into the
blood ; and, finally, in these cases of chronic constipation there may not
be sufficient toxic material in the fecal retention to produce toxemia.

This author explains the symptoms of so-called intoxication on a
more or less mechanical basis, that is to say, the distention and irritation
of the lower bowel by fecal material, with a resulting nervous disturbance
and tendency toward endocrine imbalance.

In one very interesting experiment, 5 men, normal in every way,
experienced voluntary constipation by abstaining from all call to stool
for a period of ninety hours, in wdiich cases typical signs of autointoxica-
tion developed. All but 1 developed a coated tongue in sixty hours.
The breath was markedly foul in 1 case. One individual developed
ulcerations in the mouth. The appetite was impaired in every case, and
all but 1 complained of some gas. One had nausea, the others had
no gastric disturbance. Each of them became increasingly sluggish
mentally, and they were depressed, restless and irritable. In all
instances the night's rest was unrefreshing. Laboratory tests made
within one hour after the fecal material had been gotten rid of showed
tli at in all cases the depression and mental dulness disappeared. The
author explains this marked and rapid improvement in only one way;
viz., that the symptoms cannot be taken as the evidence of a toxemia.

A number of experiments were performed on dogs in which constipa-
tion was induced by producing a closure of the anus. In 1 case
cultures of bacteria obtained from feces of the constipated patient were
introduced into a closed large bowel of a dog. Blood tests were then
made to determine whether absorption of toxins had taken place.
The author was led to believe, from these experiments, that absorption
may take place under certain conditions, and this absorption results
in changes in blood-pressure. For instance, with meat as a diet, it is
possible to show, after a reasonable period of retention, an accumulation
of poisons in the blood. Sometimes they make themselves known by
various physiologic tests. In another experiment a watery extract of
the normal feces of 1 dog showed no evidence of the presence of
poisonous substances.

In conclusion, Donaldson says, "I have no intention to deny that
cases of autointoxication of intestinal origin do exist in the constipated
who are relieved of the clinical symptoms of autointoxication immedi-

1 Journal of the American Medical Association, March 25, 1922.

THE INTESTINES 109

ately after the eliminative process. There is no intoxication, no blood
pollution and no toxic stool. I furthermore believe that the forty-eight
hour stasis, which is tic average evolution of the carmin test in sana-
torium patients, does not necessarily mean a subtle poisoning. Those
who admit definitely of constipation, and who admit of temporary relief
after an enema, ought to be treated to correct the constipation, not the
autointoxication."

Kantor,1 in discussing the treatment for constipation, calls attention
to the necessity for regularity in meal time and a normal mixed dietary,
the drinking of a liberal amount of water, and the necessity of cultivating
the habit of a spontaneous movement of the bowels at regular intervals.
This author believes that a highly concentrated dry diet is much to be
avoided. A well-balanced diet includes many green vegetables, fruits,
sugars and jams. Fatigue must be grouped among the possible causes
of constipation, but unquestionably the greatest cause is the vicious
habit formation associated with the cathartic or enema habit, as well
as an anxiety neurosis on the part of the patient. Physical exercise is
of value, the exercises which are mentioned being hill climbing, rowing,
swimming, skipping, horse-back riding and certain Swedish movements.

The Intestinal Nervous Mechanism. Muller,2 discusses the
question of the intestinal nervous mechanism. The nerves of the
intestinal tract may be divided into two groups. One is the external
group, which includes the intestinal branches of the pneumogastrie nerve,
and the mesenteric colic nerves of the sympathetic and sacral autonomic
nervous system. The second group consists of the internal nerves, which
are plexus of nerves in the walls of the intestines themselves.

This author has investigated the internal intestinal nerves with the
purpose of finding a basis for the movement of the bowel. He finds
that the mesenteric plexus is differently constructed in the stomach
and in the intestines. For instance, in the stomach the plexus consists of
typical vagus cells, the submucous plexus of squalus acanthial contains
mainly sympathetic cells and, to a lesser degree, vagus cells. The
mesenteric plexus consists entirely of vagus cells. In the musculature
and the mucous membrane of animals, sympathetic cells were found.
In the small intestine the mesenteric plexus consisted in an equal pro-
portion of vagus and sympathetic elements, while in the large intestine
the sympathetic cells predominated. The intestinal submucous plexus
consisted mainly of sympathetic cells.

These observations show that the nervous mechanism of the various
parts of the digestive tract is not uniform, as Cannon and others have
claimed. This author believes that both the vagus and the sympathetic
cells have an antagonistic relationship. The vagus cells have a motor,
and the sympathetic cells an inhibitory, effect.

Roentgen-ray Studies of the Lowter Right Quadrant of the
Colon. J. T. Case3 discusses the roentgen-ray interpretion of pain in

1 Medical Life, November, 1921.

2 Upsala lakaref. foch., Stockholm, September 1, 1921, No. 22, 36.

3 Northwestern Medicine, July, 1921.

110 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

the lower right quadrant of the abdomen. He discusses the histories
of several cases which had undergone appendectomy, in which the
principal indication for operation was the existence of chronic pain
and distress in the lower right quadrant of the abdomen. In this
discussion, mention is made of the roentgen-ray manifestations of
the colon and the necessity of studying the entire colon. Particular
stress is laid on the significance of right side colon retention as
evidence of a disturbance of the distal colon. If one considers the
movements of the colon, it is noted that the principal movements
of the ascending colon are antiperistaltic, tending to keep material in
the right side of the colon and the cecum; while the distal movements
are more of an onward churning nature. If one examines the position
and shape of the transverse colon, considerable alteration may occur
without any onward movement in the colon contents. On the other
hand, the chief propulsive factor in the large bowel is the spontaneous
large contraction involving a considerable extent of the colon, and
occurring once or twice in twenty-four hours. During this movement
the haustral markings are lost, and the movement is sausage-shaped and
rounded, and there are marked dislocations in the mass. The patient
is oblivious of any sensation, and the markings are usually seen before or
during evacuation. Case calls them "spontaneous mass movements."

The knowledge of these colon movements is extremely important in
the interpretation of the roentgen-ray pictures of the colon. Pseudo-
filling defects can be readily produced in the colon owing to its peristaltic-
activities. These errors are best avoided by supplementing the roentgen-
ography by fluoroscopy, and by the combined per os and injection
methods. Another point is the frequency of right-sided retention, which
has nothing to do with bands or adhesions, but which in reality is
associated with trouble in the distal colon. More commonly, the
obstruction is functional or spastic in character. In a number of cases,
however, adhesions to the pelvic loop, pressure of pelvic tumors, car-
cinoma, peridiverticulitis, incarceration of a prolapsed and redundant
pelvic colon, rectal lesions, such as hemorrhoids, fissure, rectal ulcers,
proctitis and rectal atony are responsible. Not infrequently, a point
just proximal to the midline in the transverse colon has been held as the
seat of obstruction, but the studies of certain observers would indicate
that this is the zone where antiperistalsis ceases. Obstruction may be
simulated by the disposition of the opaque mass after defecation, owing
to the fact that normally the colon, up to the splenic flexure, is alone
evacuated.

It must therefore be borne in mind that in many individuals the right-
sided discomfort is cecal or colic and not necessarily appendiceal, which
accounts for the dissatisfaction which attends some of these cases
following appendectomy.

Examination of the Feces. Clinical Value of the Quantitative and
Qualitative Estimation of Fats. While functional testing of the upper
digestive tract is complete regarding the proteins and carbohydrates,

THE INTESTINES 111

Ramos1 states there exists considerable difference of opinion regarding
the fats. Of the fats eliminated in the feces, 4 to 5 per cent of the whole
fat ingested are represented in this way; 25 per cent arc neutral fats,
38 per cent arc fatty acids and 37 per cent are soaps. I lis patients are
put on an exclusive milk diet for four days; the fat, protein and carbo-
hydrate content of the milk being known, the feces were then examined
for the total amount of fat, as well as the type of fat present. If the
total fat was in excess of 5 per cent, two classes of functional disturb-
ances were found; either exaggerated peristalsis or steato-dyspepsia.
The presence of an increase in neutral fats alone, indicates entero-hepatic
and pancreatic deficiency; the presence of fatty acids and soaps in
excess of 75 per cent shows an incapacity for fat absorption due to the
presence of lesions, usually ulceration, or atrophy of the intestinal
mucosa. The presence of fatty acids increases the acidity and extends
■ the ulceration and irritation of the mucous membrane. In this con-
nection, it might be well to point out that the presence of split,
but unabsorbed, fat would indicate intact pancreatic but insufficient
biliary. function.

Constipation. Panchet2 describes two forms of constipation; one
which is terminal, left -side, dyschezic, with fecal evacuations often old
and dried out involving the distal segment of the colon. This form is
only slightly toxic in its action. The other is right-sided constipation;
proximal or ileocecal with liquid stasis, septic, and almost always produc-
ing some of the signs of intestinal stasis. The terminal or left-sided
variety requires medical treatment. Dyschezia may be the result of a
congenital anomaly, rectal spasm, bad habits, or a combination of the
three. The savage has three movements a day, reacting to a postprandial
movement after meals. Mineral oil should be used regularly at begin-
ning or during each meal. Regarding the operations for right-sided
constipation; cecoplication, cecosigmoidostomy and iliosigmoidostomy,
and partial or total colectomy in one to two sittings are indicated.

Physiology of the Fats and Lipoids.3 In a voluminous article
of over 400 pages, Goiffon, in the Archiv. des Maladies del'App. Digestive,
reviews the important points of interest to the physician. Within
recent years so much attention has been paid to the protein family that
a treatise on the fats is urgently necessary.

All the fatty acids of the organism can be divided into two parts.
One is fixed and uniform in all individuals of the same species. This
form is more or less constant, while the other form is variable, and this
second form is the reserve of fats in the organism. It is the latter alone
which disappears on starvation, and which is distributed in the muscle
and cellular tissues throughout the body. On the other hand, the
liver had a more or less fixed fat content, regardless of the richness of
fat in the dietary.

The digestion of fats has nothing to do with gastric secretion (except
the liberation of fats by digestion of protein substances) . Furthermore,

1 Cron. Med. Chir. de la Habana, January, 1922, p. 167.

2 Policlinico, Rome, January 15, 1922, p. 291.

3 Annales des Sci., Naturell Zoologie, 1921, t. 4, 1-6.

112 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

the true intestinal secretion contains a lipase of little activity, playing
a very minor role in fat digestion. On the other hand, the pancreatic
and biliary secretions are the important agents in fat absorption; the
pancreatic secretion by its double action of emulsification and saponifica-
tion; and the bile by its ability not only to accelerate the saponifying
action of the pancreatic juice, but also to dissolve the products formed.
It is, however, the absence of bile which produces the greatest deficit in
the absorption of fats. The exclusion of the pancreas always makes
itself felt by a very marked loss, some 50 per cent, but it is remarkable
to note how little the pancreatic secretion is necessary to a good absorp-
tion of fats. Brugsch noted, for instance, in subtotal ablation of the
pancreas that it required but a small part, 2 to 3 cm. by \ cm., in size
of functionating pancreas to produce absorption of the fats of milk to the
extent of 80 per cent.

According to Terroine,1 all the fats are not equally saponified by the
pancreas with equal rapidity. The following are the points which he
brings out:

1. The facility with which the pancreatic secretion attacks the fats
is dependent entirely on the composition of the fatty substances, and also
their fusion point.

2. The natural fats constituted especially by the glycerides of the
saturated fatty acids are more easily saponified than those rich in
trilaurine and the neighboring glycerides.

3. The natural fats constituted especially by the glycerides of high
molecular weight are more easily saponified than those rich in trioleine.

Regardless of their digestibility in vitro, six hours after the ingestion
of fats, the fats with high iodine index — such as lamb, chicken, squab —
are much more readily digested than those of low iodine index (mutton,
veal, pork). The oils follow the same law.

The blood content of total lipoids, that is to say both the fatty acids
and cholesterol, is very different in different normal subjects of the
same species (dog). Likewise, the relationship or coefficient of choles-
terol fatty acids shows marked differences. On the other hand, the same
animal will showT a marked constancy in the lipoid content of the blood;
or the lipemic index and the coefficient cholesterol fatty acid; or the
lipemic coefficient. According to Bloor and Bang, there exists normally
a lipemic constant "constante lipemique," which is defined by the two
values ; the lipemic index and the lipemic coefficient.

The lipemic constant is more or less fixed in the same way that the
glycemic constant is fixed. Such a situation demands, of necessity, the
existance of regulator mechanisms. In the course of the absorption of
fats, an increase in the fatty acids of the blood is observed, which reaches
its maximum some six hours after a meal. Furthermore, in the course
of the absorption of fats, an increase in blood cholesterol is observed.

In the course of starvation, variations in cholesterol follow those of
the fatty acids, but the coefficient or relationship between these two
substances does not remain constant. The administration of phlorizine,

1 Abstract: Archives, des Mai. de l'App. Digestiv, 1922.

w/ a: intestines 113

in animals subject to prolonged starvation, does not result in any increase
of the fats in the liver; but it increases regularly with one exception —
an increase in the fatty acids of the blood. Here, again, the variations
in blood cholesterol do not follow those of the fatty acids.

After frequent and abundant bleeding, the serum seems to maintain
its constant in total lipoids and in the cholesterol fatty acid coefficient.
On the other hand, the suprarenal capsules which contain the normal
amount of fatty acids contain a quantity of cholesterol four times less
than that of a normal animal.

The sum total of these facts would lead us to believe that when the
blood is deprived of its proper lipoids, a regulator mechanism exists,
which tends to rapidly restore the indices and normal coefficients
regarding fats in the blood-serum. We mention these findings only
inasmuch as they throw some light on the pancreatico-biliary system
in its true relationship to fat metabolism.

Chronic Ulcerative Colitis. Yeomans' study is based on the
observation of 65 cases of chronic ulcerative colitis of unknown etiology,
of which those due to parasites, tuberculosis, syphilis and other recog-
nizable causes are excluded.

The disease, according to the author, is characterized by an acute or
gradual onset, usually between the twentieth and fortieth years of life.
Ulceration of the colon is the essential pathologic condition, and dysen-
tery (either continuous or with remissions) is the cardinal symptom, and
may run a protracted course of many months or years, and cause a
guarded prognosis to be given.

From the history, no definite cause could be assigned in 37 cases. In
5, there was a history of amcebiasis, but no amoebas or cysts were found ;
the onset dated from dietary indiscretion in 6 cases, severe constipation
in 5, exposure in 3, injury, pyorrhea, root abscesses and pregnancy,
2 cases each. It followed parturition in 1 case, and a surgical operation
in 3 cases. Search for Bacillus dysenterise (Chiga, Flexner) amoebas,
cysts, ova, parasites, tubercle bacilli and flagellate bodies was negative.
Stained smears from the stools and direct from the ulcers showed the
usual flora. Cultures from the same sources grew Bacillus coli regularly,
together with various strains of streptococci and staphylococci. The
author quotes Kendall who claims that normal bacteria may, through
unusual conditions, multiply with abnormal luxuriance, and eventually
lead to reactions within the host which may be injurious. Among
such "unusual conditions" are food toxins, severe constipation, injuries,
surgical operations, pregnancy and labor, all of which temporarily lower
normal resistance. Favoring a theory of infection, however, is the
fever and prostration often present at the onset, and later septic compli-
cations, especially arthritis. Pathologically, the process is simple
chronic ulceration. The following were the findings in this series of
cases :

(a) Superficial discrete ulcers, large or small, 20 cases.

(b) General superficial ulceration and granular areas, 20 cases.

1 Journal of the American Medical Association, December 24, 1921, No. 26,
77, 2043.

114 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

(d) Deep hemorrhagic ulcers, 4 cases.

(e) Deep, moth-eaten, closely-set ulcers, 2 cases.

(/) Superficial irregular ulceration and granulation, limited to rectum
and sigmoid, 10 cases.

Secondary complications were polyps (4 cases), rectal stricture (1
case) and arthritis or joint pains in 4 cases.

Symptoms. These were gradual in 47 cases, and acute in 18 with
diarrhea, and in 9 cases an elevation of temperature. The number of
stools varied from 3 to 20, the average being 7, and occurred mainly
in the morning and evening and seldom at night. Ten patients
were constipated. The discharge consisted of blood alone in 10 cases,
blood and mucus in 19, blood and pus in 12, and blood, pus and
mucus in 15. Blood predominated or was present in 86 per cent of the
patients.

The average weight loss was 19| pounds, the greatest being 80 pounds,
whole 25 cases showed less than 10 pounds loss. Blood count was
under 4,000,000, and in those showing marked bleeding the hemoglobin
index was 55 to 90 per cent, and leukocytes varied from 9000 to 29,000.
The average eosinophile count was 4 per cent. Gastric findings, when
performed, were normal or subnormal. Urinalysis was negative, except
for a regular increase in indican. In the majority of cases there was
prostration.

Intestinal colic and urgency before bowel action is rather charac-
teristic, according to the author, and not infrequently there is a sensation
of abdominal unrest and tenseness. Abdominal tenderness is notable
only when there is perforation or peritonitis complicating colitis. The
sigmoid colon can usually be felt as thickened, and pressure on it excites
the desire to defecate.

The diagnosis is made by the history, the laboratory examination of
the stools, sigmoidoscopy, and roentgen-ray examination of the colon.
The sigmoidoscope enables us to examine the bowel directly, and obtain
material for laboratory examination. Roentgen-ray studies should in-
clude the chest for latent tuberculosis.

In the roentgen-ray studies, non-haustration and contraction of the
colon are pictures more or less characteristic of this condition; and a
thorough roentgen-ray study will indicate the extent and type of the
pathology.

The prognosis should be guarded, depending on the duration of the
disease and the extent of cooperation of the patient with the physician.
The diet should be mixed, nutritious, and thoroughly masticated,
excluding both highly fermentative articles and those which are likely
to leave and irritating residue.

The drug treatment includes the usual tonics and antiseptics, includ-
ing arsphenamine, emetine, yeast and Bulgarian bacilli, the last by
mouth, by colonic implantation and through appendicostomy. Local
treatment consists of irrigations, instillations, and topical applications
through the sigmoidoscope. Instillations to be retained over night of

THE INTESTINES 115

warm olive oil or liquid petrolatum, with bismuth or orthoform and 1
to 2 per cent argyrol solution, are very beneficial, as is aqueous extract
of krameria. Irrigating solutions vary from plain water, salt solution,
solutions of boric acid, sodium bicarbonate, hydrogen peroxide, potas-
sium permanganate, quinine, ehloramine-T and silver nitrate. Auto-
genous vaccines were used in 10 cases, Bacillus coli communis was used
in 5 cases, and Bacillus coli and Staphylococcus albus in 5 cases.

In 3 of these cases the effect of the vaccine was prompt and 3 others
were markedly improved. It is likely, as the author mentioned, that
the usual intestinal contents can secondarily infect the ulcerations.
Transfusion of blood was done in 3 cases, with marked improvement in
2 of the cases. Surgery, in this author's opinion, is only indicated where
the above measures have failed. Irrigations through appendicostomy
cured 3 patients and markedly improved 1 of the 7 patients submitted
to this procedure. Ileostomy is preferable and even more efficient, but
it has the objection of a fecal fistula which must be closed later. The
author gives as the indication for colectomy, involvement of the entire
colon and all its walls, so that the organ is practically converted into a
pus tube. Three of the authors patients died, 2 having been treated
medically and 1 surgically.

The author's summary is as follows: 1. Chronic ulcerative colitis
is a serious disease, its victims often passing through many hands before
its true nature is recognized.

2. By the use of modern instruments of precision and laboratory
tests, its diagnosis is simple, as is its differentiation from other lesions
which cause similar symptoms.

3. Until and unless a special or specific microorganism is isolated as
the causal agent — a rather unlikely probability — the treatment is
symptomatic and empiric.

4. Treatment in the vast majority of cases is medical at first; this
failing, surgery is indicated.

5. There is need of further observation and reports of large series of
cases and serious study, especially on bacteriologic lines, by staining of
tissues and cultures, to elucidate, if possible, the obscure problem of
its etiology.

Diverticula, Diverticulitis and Peridiverticulitis of the
Small Intestine, Cecum, Colon, Sigmoid Flexure and Rectum.
A diverticulum, according to Gant,1 is a non-neoplastic outpouching
of the intestine, having a lumen which does, or did, connect with the
bowel. Diverticulitis is an inflammation of a diverticulum, and peri-
diverticulitis is an inflammation of the structures surrounding the sac.
Diverticula may be congenital or acquired, the former being divided into
true diverticula (compressing all the layers of the bowel wall) , and false
diverticula (in which several layers have given way allowing the mucosa
to pouch outward). Occasionally true diverticula become false. Rare
in the appendix, duodenum and jejunum, diverticula occur occasionally
in the ileum, are common in the cecum and very frequent in the descend-

1 Journal of the American Medical Association, October 29, 1921, No. 18, 77, 1415.

116 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

ing colon and sigmoid. Acquired diverticula are most common at the
mesenteric border and the sites of the appendices epiploica. In about
50 per cent of cases, symptoms are absent. In 13,068 autopsies, diverti-
cula were discovered 83 times, of which 39 were congenital and 44
acquired or false.

Etiology. Age, weakness, weakening of the intestinal musculature
and chronic constipation, complicated by gas and fecal accumulation,
are predisposing causes. Furthermore, the condition occurs twice as
frequently with men as with women. Wasting diseases, tuberculosis,
colitis, etc., favor its formation; hemorrhagic infarcts, worms, foreign
bodies, obesity, ulcerative colitis, dilated intestinal glands and new
growths are given as causes.

Pathologically, congenital diverticula are usually found in the small
bowel, while acquired diverticula may vary from the size of a pea
to a hen's egg, and may number from 1 to 100 or more. Diverti-
culitis and peridverticulitis may occur with thickening of the walls and
connective tissue infiltration of the sac. Perforation, adhesive forma-
tion and bowel obstruction may occur, and fistula formation into other
portions of the bowel, vagina, bladder, and even the surface of the
body.

Small intestinal diverticula (excepting Meckel's) rarely become
inflamed, but 25 per cent of the colonic and sigmoidal pouches undergo
secondary changes with definite manifestations. At first, digestive
discomfort and abdominal uneasiness, with probably constipation and
gas formation, occur. Later, there may be obstinate constipation
alone, or alternating with diarrhea, fecal impaction, and pain in the
sigmoid region; and, finally, if the bowel is occluded there is marked fecal
retention, pain, rigidity, leukocytosis and fever; and if the diverticulum
is infected, mucus, pus and blood in the stools. Perforation gives the
usual signs of spreading peritonitis, with localized pain and swelling if
abscess formation is present. The tumor may vary between the
attacks, owing to the temporary relief of gas, pus or feces.

Diverticulitis and peridiverticulitis must be differentiated from
neoplastic tuberculosis, chronic appendicitis, actinomycosis, intestinal
obstruction, carcinoma, chronic sigmoiditis, fecal impaction, encysted
foreign bodies, disease of the adnexa, chronic abscess, fistula and vesical
tumors.

One is justified in making the diagnosis if there is a history of left-
sided inflammation with periodic exacerbations, and an absence of
marked cachexia, and loss of weight.

Malignancies of the Colon. Erdmann and Carter1 discuss this
subject from their large experience in the Post-Graduate Hospital
where 129 cases came under their observation in the last six years, 15
of which were inoperable owing to metastases to other organs and 9 of
which were inoperable owing to extensive regional metastases. The
remaining 105 cases were operated on with various types of palliative
and radical operations. In fact, in their series, malignancy of the
colon occurred more frequently than carcinoma of the stomach.

1 New York Medical Journal, June 7, 1922, p. (>4<).

THE INTESTINES 117

The following is given as a classification of the sites of frequent
occurrence:

1. In the inferior division of the inferior mesenteric distribution from
the anus to the sigmoid including the so-called sigmoido-rectal junction.
This scries represented 50 out of a total of 129.

2. In the superior division of the inferior mesenteric or the sigmoid
/one proper, 37 cases.

3. The ileocolic region or the cecum and the terminal ileum, 18 cases.

4. The midcolic region considering this area to include the upper half
of the ascending colon, the hepatic flexure and the descending half or
rather the proximal half of the transverse colon, 15 cases.

5. The distal colic region including the distal half of the transverse
colon and the descending colon, 9 cases.

Regarding sex distribution, of 86 cases at the Post-Graduate, 46 were
males and 40 females. In the sigmoid there were 10 more males than
females and in the recto-sigmoid and reeto-anal, there were 10 more
females than males. The average age of operable patients was a little
over forty-nine years. Regarding the question of rapidity of growth,
it was remarked that the more youthful the patient the more rapid the
growth.

Regarding the symptomatology, this varies somewhat with the
situation of the growth. In the cecum and ileocecal region, it was
noteworthy that none of the patients showed obstruction, probably
owing to the fluid condition of the bowel contents. These cases show
early and pronounced anemia, and are often palpable. The roentgen
ray, according to these authors, is not as conclusive as for growths in
the distal half of the colon. These patients rather complain of distress,
soreness, and pressure at that point to such a degree as to arouse the
suspicions of a recurring appendicitis. Not infrequently they are
operated upon for supposed appendicitis and the true state of affairs is
overlooked by the operator. This occurred in this series in 5 cases.
Colic occurs in proportion as the growth tends to occlude the lumen and
in proportion as the contents tend to assume the solid state. Toxemias,
however, are seen more often in obstruction of the distal half.

Regarding the question of pain, occasionally these are of sciatic,
lumbar, and perineal type due to nerve involvement. Tenesmus is a
common symptom in cancers of the lower portion of the gut. Pain in
the back, a sense of incomplete defecation, blood or mucus, or both, in
the stools, anemia, emaciation, and cachexia are all symptoms pointing
to the possibility of colon cancer. In the rectal region with, or without,
infiltration, there may be sphincter failure. When there is sharp pain
without emaciation or a long history of tenesmus, mucous or bloody
stools, it rather points to perforating diverticulitis than malignancy.

After discussing the surgical aspects of the case, the authors report the
following end-results: (1) Extension of life with no foul discomforts
in those patients with existing metastases in the liver at the time of
operation was from eight to twenty-four months or more.

2. In those with no appreciable metastases in remote zones extension
of life was from months to years. In tracing these patients, they
found there were several living in each group from one to six years.

118 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

3. Regarding radium, the authors are not optimistic and mention
the fact that in the majority of cases the use of radium has not only
been negligible but even deleterious.

They consider the proctoscope and the roentgen ray of inestimable
value. Patients with the above symptoms should be carefully sub-
mitted to the above procedures and roentgen-ray examination made
both by enema and by the opaque meal by mouth.

Andresen,1 contributes an interesting and timely article on acute
intestinal obstruction. He points out the fact that this condition is a
serious one and even in the hands of the best surgeons, the mortality
rate averages over 40 per cent. The mortality from strangulated hernia,
in which the cause is more obvious probably averages 25 per cent. But
all statistics agree that the mortality rate is lower the earlier the opera-
tion after the onset of symptoms. McKenty, for instance, in 43 cases
with an average mortality rate of 40 per cent had an operative mortality
of only 11 per cent when the operation was performed within the first
twenty-four hours after the onset of symptoms. In the second period
from twenty-four to forty-eight hours, it was a little over 22 per cent;
in the forty-eight to seventy-two hour interval it was 50 per cent, and
after seventy-two hours, almost 70 per cent died. Richardson, in his
study of 118 cases by twenty-three surgeons of the Massachusetts
General Hospital, found a mortality of 41.5 per cent, with 32.5 per cent
in those patients operated on in the first forty-eight hours following the
onset of symptoms.

It was Moynihan who said that anything over 10 per cent is the
mortality of delay. This delay is obviously due to several causes,
among which might be mentioned, self medication by the patient,
inability of the average medical man to make a sufficiently early diag-
nosis, and the fact that the average medical man will often wait for the
classical text-book description, with fecal vomiting, visible peristalsis,
hippocratic facies and collapse, symptoms many of which indicate that
the patient is beyond the possibility of cure.

The author divides cases of acute intestinal obstruction into two
groups: (1) Cases of acute obstruction following a more or less long-
continued period of abdominal or digestive symptoms, such as partial
obstruction, due to deformities, bands, or adhesions whether congenital,
postoperative, or tuberculous; slowly developing obstruction from
external pressure, ulceration, new growths, or diverticulitis or from long-
continued gall-bladder irritation with the passage of the stone and not
infrequently intestinal impaction of the stone; foreign body or fecal
impaction and even paralysis of the bowel from acute local or general
peritonitis. (2) Cases in which the acute obstructive symptoms come
one suddenly without previous symptoms, such as volvulus, intussus-
ception, internal hernia, or mesenteric thrombosis.

In all cases, the pathology is the same, namely, an occlusion of the
intestinal lumen, interference of the circulation, which may result in
gangrene, perforation, or peritonitis.

1 New York Medical Journal, June 7, 1922, p. 653.

THE INTESTINES 119

The cause of poisoning has not been satisfactorily explained. Drag-
stedt has shown that toxic substances form even when all secretions and
food are removed before the loop is occluded. The fresh secretions are
not apparently toxic but, on standing, the bacterial growth which
develops in them is highly toxic. Davis and Stone have shown that if
the isolated intestinal loops are allowed to drain even in the peritoneal
cavity, no untoward symptoms develop. Dragstedt found that if these
loops were washed with sterile water and ether, one-half of the experi-
mental animals survived the operation whereas all the animals died if
this procedure was omitted. He believes that it is impossible to steri-
lize the intestinal mucosa by chemical antiseptics, even when applied
directly to the mucosa and believes, contrary to Whipple, and others,
that the mucosa of the alimentary tract does not elaborate an internal
secretion necessary to life, nor a secretion disturbed by acute obstruction
which produces proteose, but that the substances accountable for the
toxemia of acute obstruction are produced by the action of intestinal
bacteria on proteins or their end-products, while the resulting injury
to the intestinal mucosa greatly facilitates their absorption.

The symptoms of acute obstruction which are almost constantly pres-
ent are vomiting, constipation, and abdominal pain. The vomiting at
first is due to pylorospasm, but is not relieved by lavage and may occur
immediately after the ingestion of food or drink especially in high
obstruction. With lower forms of obstruction the vomiting may be
delayed for a time. On the other hand, in two to four days after the
pyloric sphincter is played out and fatigues, reverse intestinal peristalsis
sometimes from all the way down to the ileocecal sphincter may occur.

Constipation is not always so clear, and the patient may have had a
movement on the day before. Enemas which, in the beginning, may
bring a slight fecal return, may return clear and no flatus is expelled.
If the obstruction is low down but little of the enema is retained, if high
up the whole enema may be retained. In intussusception and car-
cinoma, blood may occur in the washing or may occur spontaneously.

Pain is usually a prominent symptom and may occur all over the
abdomen, although it usually occurs in the midabdomen. It is of
cramp-like character, with severer paroxysms associated with reflex
vomiting. The severe pain due to contraction of the musculature above
the obstruction is aggravated both by food and cathartics and is not
relieved by enemas. It is usually worse after the obstruction, tending
to become less as the intestinal musculature tires out. Tympany is
rare in the early stages and is really a late symptom; visible peristalsis
is likewise rare, except in postoperative cases. Shock, as well as rapid
pulse, are both rare at the onset but tend to appear as the disease goes
on, being indications of strangulation, gangrene, and peritonitis. Pal-
pable mass may be felt with carcinoma, impaction, and intussusception.
The temperature may be normal until peritonitis supervenes.

Moderate leukocytosis occurs in many cases, but marked leukocytosis
only occurs in later stages. Blood chemistry shows in the later stages
an increase in blood urea.

The diagnosis is best made on the finding of: (1) Peristaltic pain

120 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

increased by food or cathartics; (2) persistent vomiting not lessened by
lavage; (3) constipation unrelieved by enema. In early cases where
the question of whether there is true intestinal obstruction or simply
fecal impaction, the author feels justified in giving an oil enema (castor
oil and olive oil — four ounces of each) or even a moderate dose of castor
oil by mouth followed by a soap-suds enema and possibly a hypodermic
of pituitary extract. In simple impaction or paresis this usually brings
results, but if no evacuation occurs and symptoms are aggravated the
diagnosis of obstruction should be considered as fairly well established.
The author gives the following conditions which must be differentiated
from acute intestinal obstruction:

1. Acute peritonitis, from any cause in which the history, high
leukocytosis, and rigidity are aids.

2. Gall-bladder colic, in which localization and sudden onset and
cessation of pain with fever and icterus aid in the differentiation.

3. Renal colic in which the location of the pain, the urinary and
roentgenograph ic findings are distinctive.

4. Acute poisoning from food or any other agent, with a history of
having taken the irritant, with diarrhea, are important.

5. Pyloric stenosis, in which slow onset, delayed vomiting, and
roentgen-ray findings make the diagnosis.

6. Acute hemorrhagic pancreatitis, which is difficult to differentiate
but in which the symptoms call for the same treatment, immediate
operation.

7. Uremia, in which edema, with urinary findings, and blood findings
should enable one to make the diagnosis.

8. Lead colic in which the chronicity, history, and associated muscular
weakness are of value.

9. 'Angina pectoris and the crises of tabes in both of which the pains
are not as persistent and do not last as long.

10. Gastro-intestinal purpura and angioneurotic edema which
clear up rapidly.

Transformation of the Intestinal Flora. Bass1 states that the
meconium of the new-born child is sterile. Soon after the mother's milk
has gained access to the digestive tract, a mixed series of organisms appear,
giving way to a simplified flora consisting chiefly of the Bacillus bifidus,
which persists as long as the child's diet is mainly breast milk. Another
organism was claimed to be the predominating organism in nursing
stools, but it is now generally acknowledged that the Bacillus bifidus
is the most prominent. Bacillus bifidus is an anaerobe, while the
Bacillus acidophilus is facultative. When, however, a new diet is
inaugurated (particularly after cow's milk) Bacillus bifidus becomes
less numerous and Bacillus acidophilus more numerous. Only for a
time is the fecal flora of the young child dominated by the Bacillus
acidophilus; as time goes on it gradually gives way to many other types,
so that in the flora of normal adults the percentage is from 0 up to
5 or (> per cent of Bacillus acidophilus.

iCOIl'
1 Annals of Med .no, July, 1922, No. 1, 1, 25.

THE INTESTINES 121

Interesting arc the various conjectures regarding intestinal bacteria.
In 1868, Senator declared that decomposition of proteins within the
alimentary tract resulted in the formation of substances toxic to the
host. Twenty years later, Bouchard elaborated the theory of intestinal
intoxication. MetchnikoflF believed that premature senescence was the
result of bacterial activity in the intestinal canal. This gave rise to the
indiscriminate use of the Bacillus bulgaricus, but, in 1908, Ilerter and
Kendall demonstrated that the Bacillus bulgaricus cannot survive in
the intestinal canal of animals. Their experiments were on the monkey.
Distaso and Schiller, in 1914, found the same thing with white rats, and
Kalic, in 1915, confirmed these observations. Finally, Rettger and
Cheplin found it impossible to recover Bacillus bulgaricus from the
feces of man after feeding with the organisms.

Diet has been shown to have a profound effect on intestinal flora.
Herter and Kendall found rapid alterations in the intestinal flora of
both cats and monkeys when a diet of meat and eggs was followed by
one of milk and dextrose; there being a substitution of an aciduric non-
proteolizing type for one which was formerly strongly proteolytic. As
the food varies, so will also the bacteria vary. Hull, Rettger, Distaso
and Schiller observed the profound effect of lactose in changing the
flora of animals from a putrefactive to an aciduric type. Torrey, in
1915, found that it took 250 to 300 grames of lactose a day to transform
the fecal flora of typhoid patients from the usual mixed type to that
dominated by the Bacillus acidophilus. Finally, in 1921, Rettger and
Cheplin published a monograph on the subject of intestinal flora, in
which they emphasized the fact that when either lactose or dextrin was
fed in addition to the usual diet to the amount of 2 grams daily, a
progressive increase in Bacillus acidophilus could be noted in two days,
reaching its maximum in four to eight days. As the Bacillus acidophilus
increased, the gas-forming putrefactive bacteria decreased, and finally
disappeared. With men, 300 grams of lactose or dextrin, daily, cause
practical elimination of all other bacteria except Bacillus acidophilus,
while smaller amounts (150 grams or less), although increasing the
acidophilus population, failed to make any noticeable impression on the
other bacteria present. On the other hand, from a practical viewpoint
the Bacillus acidophilus was fed by mouth. Sometimes 500 cc produced
complete transformation, while in others 1000 cc daily was necessary.
Again, wThen reinforced with lactose, smaller amounts of the culture
gave practically the same results as large quantities. For instance, 500
cc of the culture plus 150 grams of lactose produced practically the
same effects as 1000 cc of the culture or 300 grams of lactose. Bass
studied the effects on men of Bacillus acidophilus milk cultures, using
1000 cc a day, with a complete change in the fecal flora. Out of curiosity,
Bass examined some of the commercial preparations and none of the
commercial tablets contained as many as 1000 viable bacteria. It
would therefore take 1,000,000,000 tablets, or some twenty tons of
tablets, to contain as many bacilli as are contained in the 1000 cc of
Bacillus acidophilus milk. All the observer needs is fresh cultures of the
organism which should be inoculated into sterile milk, using relatively
large quantities, some 10 cc or more to the liter.

122 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

Gompertz and Vorhaus1 discuss the question of the Bacillus acido-
philus, its bacteriologic characteristics, the preparation of media and
the possibilities of this form of therapeusis. The main points mentioned
by Bass are reviewed and the following directions are given for prepar-
ing cultures:

These observers gave Bacillus acidophilus cultures in both chronic
constipation and diarrhea, with material improvement. Of 50 cases of
chronic constipation, 42 gave good results, and in 10 out of 12 cases of
chronic diarrhea improvement was noted.

When the administration of the culture ceases, the Bacillus coli begin
to increase, slowly at first until the fifth or sixth day, at which time they
again present the predominating type of bacteria. If lactose or dextrin
is included in the diet, this transition may be retarded considerable.

At first fermented milk was given. This was prepared by inoculating
sterile milk with Bacillus acidophilus and allowing it to incubate at
37.5° C. for from forty to fifty hours. Either whole or skim milk may
be used. The dose is from a pint to a quart daily given preferably
before meals in amounts ranging from one-half to one tumblerful. This
method, however, proved to be inconvenient from a practical standpoint,
thereby necessitating a different means of administration. A broth
culture in which this bacillus grows luxuriantly, giving the optimum
concentration, was finally used.

The broth is so prepared that each cubic centimeter contains 100,000,-
000 Bacillus acidophilus organisms and the dose is from 10 to 20 cc either
two, three or four times a day, before meals, depending entirely upon the
response of the individual.

The technic of preparation of the broth is simple, and is as follows:

1. To 1000 cc of distilled water add 4 grams Liebig's meat extract,
10 grams peptone (Merck's) and 5 grams sodium chloride B NaCl.

2. Heat over free flame until thoroughly dissolved, stirring constantly

3. Titrate and adjust to required reaction pH 6.9-7.0 neutral.

4. Sterilize in one-liter flasks for one hour in Arnold sterilizer.

5. Filter bouillon cold the next day through filter paper, until clear.

6. Add to clear bouillon, to 1000 cc 50 grams of lactose; 5 per cent;
shake well, until sugar is dissolved.

7. Pour media in flasks (300 cc) in one-half liter flasks.

8. Place the flasks stoppered with cotton in the autoclave for
twenty-five minutes and sterilize at 15 pounds pressure.

These flasks are then inoculated and incubated at 37.5° C. for about
sixty hours. They are then removed and the clear supernatant fluid
is decanted. This simple procedure gives approximately a concentra-
tion of 1,000,000,000 bacilli to each cubic centimeter. The culture is
then distributed in sterile 8-ounce bottles and kept cool until used.

In this medium Bacillus acidophilus grows luxuriantly, although
growth is not perceptible until the end of forty-eight hours. This
fact is of considerable practical importance, for it affords a simple and
yet accurate means of determining the purity of the growth. The

1 Annals of Medicine, July, 1922, No. 1, 1, 33.

THE TNTESTINES 123

usual laboratory contaminants, which are the Bacillus subtilis and
Staphylococcus albus, show a luxuriant growth in this medium at the

end of twenty-four hours. Furthermore, these contaminants arc more
or less evenly distributed and contaminated flasks show a uniform
density. The growth of Bacillus acidophilus, however, is a thick,
heavy, slimy growth which settles quickly to the bottom and leaves a
clear supernatant layer of bouillon above. Thus the contaminated
Husks are easily detected and thrown aside.

The Bacillus acidophilus is Gram-positive, varying in shape from short
to long rods. On lactose agar, it forms small, whitish-gray colonies
with wavy margins. It grows slowly, being hardly perceptible at the
end of twenty7four hours. This organism ferments milk, producing
acid slowly so that the milk does not usually begin to sour until incubated
for about thirty to thirty-five hours.

Choplin and Wiseman made a study of Bacillus acidophilus milk
upon cases of chronic constipation. It was their purpose to determine
the therapeutic value of acidophilus lactose milk on chronic constipation.
This milk was prepared in accordance with the method advocated by
Choplin and Rettger, in 500 cc amounts, and living twenty-four hour
cultures were given to these patients daily. In most instances 500 cc
of the milk were reinforced wTith 100 grams of lactose, and this quantity
was ingested by the patients each day in two equal doses. This milk
was given in addition to the ordinary diet, and during the period of
investigation no laxative or cathartic was permitted.

Bacteriologic examination of the stools revealed in most instances
a prompt response, and daily evacuations were recorded. In some
cases it was necessary to double the quantity administered.

It is, therefore, evident from these observations that the tendency
of acidophilus lactose milk was to regulate the intestinal movements
and also to change intestinal bacteria. Within a few days these results
were obtained, the mixed bacterial types giving way to a simplified flora
in which the bacillus acidophilus predominated.

Chronic Intestinal Indigestion of the Fermentation Variety.
Jankelson's1 communication deals with the well-recognized fermentation
type of intestinal disturbance. These stools are the large, bulky,
light-colored stools with the acid reaction and sour odor. They are
usually light-colored, distinctly acid to litmus, contain considerable
undigested material, especially vegetables, and give a strong iodine
reaction for starch. Occasionally it is possible to obtain an erythro-
dextrin reaction of partially digested starch. Microscopic examina-
tion usually reveals undigested starch granules. The movements are
acid owTing to the acid of fermentation, particularly acetic and butyric
acid. Disease is supposed to be due to the overgrowth of fermentative
bacteria, and, when no carbohydrates are ingested, these bacteria simply
starve out or become markedly lessened in number. These patients
usually develop an early colitis and the chief complaint is persistant
diarrhea, distention of the abdomen, rumbling, and even occasional

1 Boston Medical and Surgical Journal, May 4, 1922, 186, 597.

124 REIIFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

nausea or vomiting. Later on there is no question but that a moderate
degree of toxemia develops, usually dizziness, vertigo, headache,
insomnia, irritability, and later a well marked neurasthenia.

The treatment consists entirely in starving out these bacteria by
means of a pure protein and fat diet. Carbohydrate is then given in
increasing amounts, but it is usually necessary to avoid vegetables and
fruits for some months. In many of these cases it may be noted that
there -is enterocolitis and not infrequently a low grade catarrh of the
entire digestive tract. (Reviewer.)

Norman and Eggston1 discuss the important subject of pyogenic
infection of the digestive tract. These authors report 3 cases exemplify-
ing intestinal infections which were relieved by removal of focal infection
and colon drainage.

In later years one of the most important advances in modern medicine
has been the definite establishment of focal infection, particularly the
evident infections which are freely accessible, such as the teeth, tonsils,
sinuses, nose and throat. Less evident are the cryptogenic infections,
such as those of the appendix, gall-bladder, and the digestive tract.
These authors are of the opinion that in many instances intestinal stasis
or constipation is the result of intestinal infection. There is no question
whatsoever that a removal of the upper foci of infection frequently
results in failure as long as the intestinal condition is persistant. Direct
autopsy observations of the intestinal tract, particularly of the colon,
cultures of the feces, the mesenteric lymph nodes and the gall-bladder
contents would indicate that they are all infected by the same organisms.

With pyogenic infections the treatment resolves itself into: (1)
Drainage of the colon; (2) changing the biologic process by a rectal
and oral implantation of the protective forms of bacteria; (3) by main-
taining a normal bacterial flora in the bowel ; (4) by the use of autogenous
vaccine in selected cases; (5) by properly selected exercise to strengthen
the abdominal wall and to stimulate lymphatic drainage.

Vanderreis2 discusses the bacterial flora of the small intestine and
cecum in adults under normal and pathologic conditions. This
author uses the so-called cartridge and found that the small intestine
was fairly free from bacteria during the fasting condition but was not
absolutely sterile as is generally supposed. The upper part of the small
intestine contains Gram-positive bacteria mostly of the lactic acid type,
diplococci and Gram-negative bacteria of the aerogenes group. The
middle portion of the small intestine showed a greater number of
bacteria but with a reduction in the acid type of bacteria, and with an
appearance of the general colon type as well as other Gram-negative
organisms. As we go down the small intestine, the Gram-negative
bacteria increase. The cecum contains the starch fermentating anerobes
Clostridia and bacteria which form the hydrogen sulphide. Of course,
the diet greatly contributes to the flora. For instance, a predominance
in the carbohydrate diet produces the lactic type of bacteria, but
fermentative dyspepsia is often accompanied by a predominance of the

1 New York Medical Hour, April 19, 1922, 115, 449.
* Berlin klin. Wchnschr., May 6, 1922, 1, 950.

THE INTESTINES 125

Gram-negative bacteria. There is also in that condition a striking
reduction in the number of organisms which ferment cellulose. Another
interesting point is the statement that there is an increase in the number
of bacteria in the upper small intestine with subacid and anacid condi-
tions, and there is a diminution in the number of bacteria in the upper
pari of the intestinal tract with hyperacidity.

Observation on Lamblia Entestinalis [nfection and [ts Treat-
mi at. Simon1 gives a short clinical description of 8 eases of lamblia
intestinal infection. In 5 of these cases there was no history of diarrhea,
while in the other 3 cases the diarrheal phases occurred irregularly
alternating with periods of constipation. Another point of interest was
the fact that blood was not apparently a characteristic of these stools,
a point which might differentiate them from the amoebic type. In almost
every instance there was considerable abdominal gas, often producing
cramp-like pain. Loss of weight was only recorded in 3. In 1 case
there was an inflammatory condition of the gall-bladder, and duodenal
intubation showed the presence of organisms of this type. In making
the diagnosis one can be solely guided by the discovery of these organ-
isms in the stool or in the aspirated secretions of the upper intestinal
tract. As a matter of fact, the organisms inhabit for the most part the
duodenum and the jejunum, and may even find their way into the
biliary passages. The encysted forms, however, can be found through
the whole intestinal tract, and, when studied by careful microscopic
examination, usually show up in showers.

In recording the treatment, it is noted that both emetine and ipecac
are of no value in this form of infection. In one case with transduodenal
lavage with Jutte solution, the cyst promptly disappeared. In 6 of these
cases, however, arsphenamine, according to the suggestion of Yakimoff,
in 1917, was used, and in 1 case the drug was introduced directly through
the duodenal tube. In each instance there was a prompt disappearance
of the cysts from the stools.

Knighton,2 discusses the possibility of these organisms in the biliary
tract, and was able to demonstrate these organisms in the aspirated bile.
He comes to the conclusion, however, that transduodenal lavage or
duodenal drainage gives only temporary relief.

Lamblia Enteritis. While lamblia or Giardia were encountered in
France before the war, the cases have multiplied since then, and systemic
examinations of the stools have revealed a large number of cases.
Deschiens3 has made a morphologic, clinical and experimental study
of this condition and believes in the unity of the types of Giardia. The
idea of dividing them into two species (9 intestinalis and 9 muris) is
based on little variation in structure, and the fact that both present
similar phenomena in infected cats would militate against this sub-
division.

Mice and cats have been infected by the ingestion of human cysts,
and 2 cats were infected by rectal injection of the living organisms.

1 Southern Medical Journal, June, 1922, p. 458.

2 Ibid., p. 457.

3 These, Paris, 1921.

126 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

They provoke diarrhea and even fatal dysentery. Ulcerative and
erosive lesions are found in the lower third of the ileum, and even
massive exfoliation and hemorrhage.

According to this observer, gastric acidity does not prevent infection.
The cats registered an acidity of free HC1, 2.5 per cent. Studies on
11 cases in man emphasize the persistency of the infection, and show in
some cases chronic enteritis, and in others even dysentery.

Treatment of Hookworm Infection with Carbon Tetra-
chloride. Nichols and Hampton1 used this drug for the treatment of
hookworm infection in school children. The treatment is carried out in
such a way that the stools were examined both before treatment, three
days after treatment, and ten days later. Two-thirds of the worms were
passed on the second day. This drug is given in doses of 10 to 20 drops
to children three to four years of age, and is apparently an effective
remedy against hookworms. It may even be used for the round-worm
but is not as effective as some of the ordinary remedies. Children of
ten years of age may be given 10 drops with safety, and the dose should
be increased 2 drops for each year. An adult dose would be to add 50
to 80 drops. Chenopodium is soluble in carbon tetrachloride. A good
mixture of one of the former to four of the latter should prove to be an
effective remedy for the expulsion of round-worm, or Ascaris lumbri-
coides.

The following reasons are given for the use of carbon tetrachloride in
hookworm infection: (a) Patient does not object to its taste, (b) It
is not necessary to precede or follow it by a purge, (c) It is more
effective than chenopodium and has not the depressing effect of that
drug, (d) It is much cheaper than any other drug used for the purpose.
(e) It can be obtained in a high state of purity. (/) Persons under
treatment can follow their usual routine.

Constipation. Heisland,2 in discussing constipation, mentions the
fact that while a daily evacuation of the bowels is usually considered a
normal phenomena, nevertheless many individuals defecate at longer
intervals and seem to be perfectly normal. Some of these individuals
should not alter their habits, inasmuch as the delay does not seem to
be incommensurate with perfect health. The treatment of constipation
by means of diet alone is successful in many instances if the patient will
only stick to the proper diet.

In a general way, protein foods constipate, and vegetables and fruit
are laxative, but with many individuals the latter act in the reverse
fashion, and there seems to be no question but that a mixed diet is suited
to the needs of the ordinary individual. In this paper it is suggested
that bread made from fine flour be eliminated. The following is simply
a suggestion : A glass of cold water on arising. For breakfast : Oatmeal
not too well cooked, Graham or whole wheat bread, butter, coffee with
cream and sugar, raw or cooked fruit and marmalade. For dinner:
Fruit, two vegetables, corn bread, butter, milk, occasionally meat, and

1 British Medical Journal, July 1, 1922, p. S.

2 Kentucky Medical Journal, March, 1922, 20, 194.

THE INTESTINES 127

a dessert if desired. For supper: Corn bread, butter, one or two vege-
tables, syrup or fruit sauce, buttermilk.

( 'arles1 discusses the treatment of chronic constipation. This author,
in reviewing the cases of chronic constipation and their treatment,
comes to the following conclusion: First of all there is a psychic form
of chronic constipation. This occurs in individuals who obviously
neglect to attend to the regular defecation, with the result that there
is an undue accumulation of material in the rectum and the consequent-
ing blunting of the reflexes concerned in this act. With the individuals
who are obviously of a hysterical type, psychotherapy may be necessary,
but in most individuals it is a question of correction of diet and the
regulation of habits. There is another form of constipation which is
due to disturbance in the colon musculature and also to an obvious
relaxation of the intestinal wall. Exercises and a properly regulated
belt are indicated in this case. Another form of constipation is that
of alimentary origin. In this group of cases the diet is not well balanced
and may be insufficient, or there may be an excessive meat diet with
insufficient residue to stimulate intestinal peristalsis; or, on the contrary
owing to the excessive injection of vegetables, there may be an accumula-
tion of too much cellulose in the bowel, hindering complete evacuation.
The obvious relief for this condition is the proper regulation of the diet.
There is undoubtedly a form of constipation due to secretory causes,
causes which may be due to an increase in the gastric acidity or to an
insufficiency of liver or intestinal secretion; and, finally, endocrine
insufficiency.

There is also a mechanical form of constipation due to adhesive bands,
tumors and even organic stenosis of the bowel, in which surgery is
obviously indicated. Some of these cases are tuberculous or syphilitic,
in which case proper medication is indicated. There is another form of
constipation of purely intestinal origin, such as is seen in cirrhosis of the
liver. In this group of cases the fault is probably due to the passive
congestion as a result of stasis of the portal vein. Still another large
group of causes of constipation are the chronic inflammatory group,
and, finally, one might enumerate the group of intestinal disturbances
which are purely due to nervous influences, some of them reflex in
origin, some of them central, such as hysteria and psychasthenia, and,
finally, those which are purely spasmodic and might have local reaction.

Ringer and Minor2 discuss the good effects of the administration of
calcium chloride in tuberculosis diarrhea. They had treated 30 cases
with 5 to 10 cc of a 5 per cent solution of calcium chloride given by
intravenous injection at more or less frequent intervals. In many of
these cases the calcium was given simply as a palliative measure, but in
all but 8 cases there was extensive disease of the lungs, and in 16 cases
there was no possibility of recovery, even though the intestinal symp-
toms were improved. In giving this material, great care must be exer-
cised in order that none of it escapes in the subcutaneous tissue where

1 Jour, de Med. de Bordeaux, May 25, 1922, 94, 295.

2 American Review of Tuberculosis, p. 876, Abstract, Medical Review, July, 1922,
p. 184.

128 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

it is apt to give severe pain and even cause necrosis. It also should be
given slowly.

In 13 cases there was no benefit observed. In 1 case the number of
movements was reduced from 5 to 1 or 2 a day, and codeine, which had
previously been given to relieve pain, was discontinued. At first the
effect of the injection lasted a month. After three months the interval
was cut down to one of three weeks, and after twenty months it was
reduced to one of ten days, and the dose increased from 5 to 8 cc.
In another case, with considerable pain, had 3 to 5 movements a day
even though 2 grains of codeine were given; the first injection removed
all pain which never recurred, and the stools were reduced to 2 or 3 a
day without the use of any codeine. Another case of severe diarrhea with
considerable abdominal distress was greatly relieved by the injections.

The authors are optomistic as to the value of this treatment and believe
that with the more refined methods the treatment may even prove
curative if given early enough.

PERITONITIS.

The peritoneum represents that great serous membrane which in-
sures a protective surface to the abdominal viscera and permits
free play of these organs one on the other. Normally, the relation-
ship between absorption and exudation is so balanced that even
a small amount of free fluid in the abdomen means pathology. Peri-
tonitis, almost always a bacterial infection, tends to be walled off by
adhesion formation. The most common source of bacterial infection
is directly from some intra-abdominal organ, such as the appendix, the
intestines, the female generative organs, the stomach, the gall-bladder,
the result either of trauma, disease or both. Although there is such a
condition as chemical peritonitis, produced by the introduction of
presumably sterile instruments in the abdomen or the contents of some
ruptured ovarian cyst, nevertheless, Deaver1 feels that even here the
condition is probably infection due to lessened resistance on the part
of the peritoneum. Hyperemia, exudation into the subperitoneal tissue
around the lesion, soon followed by the exudation of fluid into the peri-
toneal cavity, are the steps in the elaboration of an ordinary case of
peritonitis. Even sterile substances will induce irritation of the peri-
toneum, such as, for instance, blood, bile or urine. When present, they
interfere with intestinal function, damage the walls of the bowel, and
favor bacterial invasion of the peritoneum. In the presence of perfora-
tion with infected material, naturally an infective and irritative peri-
tonitis will be produced.

Shortly after the inauguration of irritation and inflammation, disturb-
ances occur in the rate of exudation and absorption. The absorption
occurs through the bloodvessels and lymphatics. Fluid and soluble
substances are absorbed by both sets of vessels, but acid substances,
such as bacteria and animal cells, are almost exclusively absorbed by the
lymphatics. On the other hand, according to Deaver, absorption by the

1 New York Medical Journal, September 7, 1921, p. 257.

PERITONITIS 129

blood-stream constitutes one of the greatest perils of peritonitis. At
times the area involved may be well walled off, the rest of the peritoneum
being practically normal and more or less protected against its invasion.
Diffusion is encouraged by body movement, and practically we attempt
to lessen movement by putting the body at complete rest, and by means
of the proper posture encourage the gravitation of noxious fluids to the
lower and less dangerous portions of the peritoneal cavity. It is well
known that peritonitis arising from the lower portions of the peritoneal
cavity are less serious than those coming from the upper zones, because
the greater activity of absorption in the diaphragm, in the upper portion,
favors diffusion.

The most important bacterial flora in peritonitis are the Staphylo-
coccus albus, colon bacillus, streptococcus, pneumococcus, typhoid
bacillus and gonococcus. According to the author, great stress is laid
on the protective influence of the Staphylococcus albus, which, according
to Dudgeon and Sargent, is the first to appear and the last to disappear
in peritonitis of intestinal origin. In the presence of abundant phago-
cytes and staphylococci at a site distant from the focus of infection, the
prognosis is favorable; it is grave, but not hopeless, if some bacilli are
associated with these organisms, and very grave if only a few phagocytes,
few staphylococci, but numerous bacilli and streptococci are found.
The importance of the colon organism is recognized, but it is realized
that this organism, after it is present, multiplies rapidly and tends to
overshadow other organisms present. Streptococcic peritonitis is more
frequent in women, owing to its greater frequency in pelvic infections.
When due to pelvic inflammations, it is often a retroperitoneal inflam-
mation, familiarly known as concealed erysipelas. Another form of
streptococcic peritonitis is encountered in which the condition is not due
to any abdominal organ, but presumably by hematogenous infection,
most frequently from some acute infection of the nasopharynx, such as
the tonsils. Pneumococcic peritonitis is rare, and as a complication of
pneumonia it occurs, according to Hertzler, in less than 1 per cent of all
pneumonias. Gonococcic peritonitis is one of the most clearly defined
types, generally arising from an infected Fallopian tube with early
localization in the lower abdomen. The most frequent cause of
peritonitis is, however, perforation of an abdominal viscus, and the
organ which is the commonest offender is the appendix.

The symptoms naturally vary, depending on the type of lesion. In
appendicitis, the initial pain is usually severe, owing to occlusion of the
appendicular artery and subsequent necrosis. Later, when necrosis is
complete, the pain may lessen, lulling the patient into a false sense of
security. Pain often with chilliness, reflex nausea and vomiting,
rigidity and exquisite tenderness of the abdominal muscles, the peri-
toneal picture of the patient with legs drawn up, superficial and costal
breathing, and, finally, small, frequent, thin pulse — are symptoms too
familiar to mention. The temperature, usually low at first, becomes
higher, then abdominal distention and tympanities occur.

Deaver warns against the danger of purgation. Sixty per cent of his
cases gave a history of purgation, and 72 per cent of these showed pus,
abscess, gangrene or perforation.

130 REHFUSS: DIGESTIVE TRACT AND ALLIED ORGANS

Localization of the infection is, of course, important, and infections
of the pelvis are less dangerous than those higher up. Naturally, the
mesentery, and particularly the great omentum, are of great value in
walling off a lesion, but the important point regarding the lesion per se
is the question of the intactness of its endothetial lining and the virulence
of the organism.

Regarding the time of operation, the author naturally agrees with
immediate operation for perforation or acute obstruction, but states
that "he who operates in a case of acute diffusing peritonitis after the
first thirty-six to forty-eight hours with no evidence of a localizing point
is, in the majority of cases, not serving the best interests of the patient."
Again, "too thorough operation in peritonitis very often spells death.
Peritonitis is dangerous directly in proportion to absorption. It is not
the inflammation of the peritoneum which is fatal but the toxins which
are absorbed from the products of inflammation which is fatal."

SPLEEN.

The Spleen and Digestion. Inlow.1 For a long time it has been
assumed that there was some relationship between the spleen and the
pancreas. For instance, Besbokaia and Bellamy emphasize this fact,
inasmuch as the latter considers the splenic internal secretion to be car-
ried to the pancreas by means of certain elements in the blood-stream,
and Herzen states that the pancreas of the dog deprived of its spleen
exists in a state of complete and permanent atrypsia. Mendel and
Rettger, of Yale, concluded, from their work, that extracts of the spleen
prepared when the organ was congested during digestion increased the
proteolytic power of the pancreas, while the boiled pancreatic splenic
extract was ineffective. They claimed, however, that the extracts of the
pancreas of splenectomized dogs were not always free from trypsin.
Prym, in 1904-1905, used permanent pancreatic fistulas in his investiga-
tions, and he came to the conclusion that the amount of proteolytic
power of the pancreatic juice was not influenced in any recognizable
way by splenectomy. Further observations on two dogs with per-
manent pancreatic fistulas were made by Lombroso and Manetta, in
1915. They believe that the three enzymes of the pancreatic juice do
not vary in any way after the removal of the spleen, but that the amount
of pancreatic secretion increases to a remarkable degree. The idea,
therefore, of Schiff-Herzen, that the spleen during this active phase of
congestion liberates a substance into the blood stream which transforms
the zymogen of the pancreas into active trypsin, has therefore many
investigators who would substantiate this theory.

On the other hand, there are others who are unable to prove it, and
the present author in his summary gives the data concerning the pan-
creatic secretion before and after removal of the spleen on two dogs with
permanent pancreatic fistulas secreating an inactive proteolytic juice.
Removal of the spleen in this instance caused no constant changes in the
enzyme content or the alkalinity of the pancreatic secretion.

1 American Journal of the Medical Sciences, July, 1922, No. 1, 164, 29.

NEPHRITIS.

By H. RAWLE GEYELIN, M.D.

The older text-books of medicine dealing with most, if not all, of the
diseases known to medicine are being gradually relegated to the archives
of the past and in their place we have the newer and more massive text-
book commonly spoken of as "A System" of Medicine. Whereas the
older text-books owed their authorship to one, or, at most, two men —
the modern "system" is a compilation of medical knowledge brought
together by the united efforts of many men — all of these men having
had unusual experience in certain diseases or in certain groups of diseases.
The striking additions to our knowledge of medical science which has
been made during the past twenty years have necessitated this step,
and at present it would certainly seem to be the best method of assem-
bling medical knowledge for the benefit of the enquiring students of
medicine.

The increasing number of these systems of medicine published during
the past two years would seem to be an answer to a demand for them.
Several of these systems are so painstakingly done — certain diseases so
completely and masterfully presented, and accompanied by brief reviews
of the current literature, that it would almost seem to be an unnecessary
and gratuitous procedure to add any further critical review's and con-
densations of current literature pertaining to any one disease such as
nephritis.

Nevertheless, in the present article which deals with a review and
critical consideration of the more important and interesting articles on
nephritis during the past year, I shall aim to present not only the
newer points of view of the more recent workers in nephritis, but will
also attempt to correlate these points of view wTith wThat is definitely
established in our knowledge of renal diseases in greater detail than is
possible in the systems of medicine.

There have been many articles dealing with one or another phase of
nephritis published during the past year which add little or nothing to our
present knowledge of this much-studied disease. These articles are
interesting merely as repetitions of well-known facts. To the extent
that they amplify or confirm our present knowledge, they are of certain
value but no attempt will be made to review them all. As is usually the
case, there are fewrer articles which add somewhat to our present knowl-
edge of facts and fewer still which contribute any new facts. As
compared with the epoch-making discoveries of Banting and Best in
diabetes made during the past year, the advances made in the problems
of nephritis are insignificant.

132 GEYELIN: NEPHRITIS

Tests for renal function, continue to interest the largest number of
investigators. Xo important new tests for kidney function have been
presented, most of the work being confined to elaboration and mathe-
matical refinement of old tests or to the correlation of certain groups of
functional tests with certain clinical types of nephritis.

It is more than ten years ago since Rowntree demonstrated the use-
fulness of the phthalein tests for determining the functional capacity of
the kidney in clinical nephritis. Since then many opinions have been
expressed regarding the significance of this test in measuring "total
renal function." The difficulty that presents itself in determining the
value of this test as a measure of " total renal function" is due to the fact
that not all the factors that go to make up "total renal function" are
as yet known, while others are not fully understood.

Clinical and Functional Data. From the standpoint of clinical
value of the phthalein test in cases of nephritis there are certain facts
which stand out and which are generally accepted. These facts Mosen-
thal1 presents in a brief and concise summary of the clinical value of the
"phthalein test," as follows:

"The worth of the phthalein test has been established by too numerous
observations for individual mention. The normal excretion of the drug
in two hours after the intramuscular injection is 60 per cent; diminishing
values to zero may be found; life is comfortable with no elimination of
phthalein whatsoever, though the outlook is always serious under any
circumstances — (the author has noted one case in which life was main-
tained for a period of two and a half years though repeated tests during
that time showed that no phthalein or only traces would be present in
the urine). Usually any figure of 20 per cent or less may be regarded
to be of serious omen."

To the above statements may be added the following: Phthalein
excretions above 20 per cent and up to 40 per cent do not invariably or,
in fact, commonly, measure with graded mathematical accuracy the
corresponding degree of renal impairment. As a matter of fact, there
are cases of nephritis where individual readings of 30 per cent excretion
of phthalein are found when the subsequent course of the case, the other
functional tests and even subsequent phthalein determinations do not
substantiate the original phthalein finding, and the case may actually
have no symptoms of impaired renal function. Instances in which the
phthalein excretion is normal with accompanying low renal function,
as shown by other tests and the clinical symptoms, are also found, but
they are not common.

Mosenthal goes on to say : " In certain conditions in which the kidney
may be considered as being "irritated" or overactive, there is a distinct
elimination of phthalein above the normal. Lewis has shown how this
phenomenon occurs in early chronic diffuse nephritis, fever, hyper-
thyroidism and in some cases of hypertension. Such "supernormal"
phthalein figures are accompanied by similar findings in the urea excre-
tion ....

1 Endocrinology and Metabolism, vol. 4, p. 353.

CLINICAL AND FUNCTIONAL DATA 133

"In nearly all forms of nephritis apparently the idea of Marshall and
Kolls that the amount of phthalein eliminated depends upon the amount
of actively functionating kidney substarfce seems to hold true."
(Whether the individual components of the functioning whole he
glomeruli or tubules, i. e., "total renal function"). "There is one
form of nephritis, the so-called parenchymatous, (characterized by
albuminuria, diminished salt excretion and edema), in which the phtha-
lein may be put out only in normal amounts but even in still larger
quantities. Thus, Pepper and Austin report 1 such case in which
as much as 82 per cent was found in two hours and Baetjer 4 cases
with outputs varying from 69 to 90 per cent. These findings and those
mentioned in the preceding paragraph are reminders of the fact that
nephritis is a disease whose severity in some instances cannot be measured
by renal function alone."

During the past year there have appeared a host of articles dealing
with various forms of clinical nephritis. Many of these articles include
well-planned series of functional tests illustrating degrees of renal
impairment at various stages of certain forms of nephritis and paralleling
the clinical symptoms.

Thus, Killian1 reports 2 cases of bichloride poisoning with recovery;
both cases at the height of renal impairment showed marked nitrogen
retention in the blood and a well-marked acidosis. Both patients also
showed a marked drop in the chloride concentration of the whole blood,
this drop reaching its lowest level at the time of maximal renal impair-
ment, as shown by the other functional tests. In 1 case the drop in
plasma chloride was from 0.495 per cent to 0.114 per cent, while in the
other the drop was only to 0.382 per cent; in neither case was there any
edema. This phenomenon of plasma chloride reduction which has been
noted by other observers (see Killian's article) also occurs in other forms
of nephritis, more particularly after salt restriction. The well-known
fact that we rarely find edema in the form of nephritis produced by
bichloride of mercury is confirmed in the 2 cases reported by Killian,
as neither of his cases showed this condition. The output of urine
during the twenty-four-hour period was only "moderately increased,"
and, as has been shown by Myers and Fine2 blood dilution does not
account for the lowered chloride concentration.

Similar findings regarding the concentration of blood chlorides in
pneumonia during the active stage of the disease have been made by
several observers.

Funk and Weis3 report another case of nephritis produced by bichloride
of mercury poisoning; this patient also recovered, these authors note the
high values for retained nitrogen in the blood, the retention reaching
its maximum during a period of anuria. With the gradual onset of
clinical improvement and increasing urine output, normal figures for
the non-protein nitrogen of the blood were found to obtain.

Concomitant with these observation, the authors have made estima-

1 Journal of Laboratory and Clinical Medicine, December, 1922, No. 3, 7, 129.

2 Journal of Biological Chemistry, 1915, 20, 391.

3 Journal of Laboratory and Clinical Medicine, January, 1922, No. 4, vol. 7.

134 GEYELIN: NEPHRITIS

tions of the phthalein and have also observed urea concentration test of
McLean and Wesselur.1 To quote from Funk and Weis's, "This test
depends upon the decreased concentrating power of a diseased kidney
and it is performed in the following manner: Fifteen grams of urea
dissolved in 100 cc of water, flavored with a tincture of orange and given
by mouth after the patient voids. Urine is passed at the end of one
hour, and at the end of two hours both specimens being measured,
and the second saved for analysis. In those cases showing an ex-
cretion of from 350 to 600 cc, or more, in the two hours, any tendency
to a low concentration may be put down to excessive fluid, not to
kidney disease. If the individual can concentrate urea in the second
hour specimen to 2 per cent or better, his kidneys are considered efficient ;
if less than 2 per cent, diseased; and the lower the concentration the
greater the structural damage."

The authors point out that this "urea concentration test in this case
varied directly with the phthalein" and that it is a valuable functional
test, although they seem to conclude this from this one case alone.
They also claim that the administration of the extra urea is made
without harm to the patient.

The fact that plasma chlorides and the excretion of chlorides in the
urine are diminished in severe nephritis produced by tubular poisons
is demonstrated by Major.2 This author presents a very carefully and
admirably studied case of almost pure tubular nephritis (confirmed by
autopsy) produced by chronic acid poisoning. Nitrogen retention in
the blood and a lowered blood bicarbonate, as observed by Killian in
mercurial poisoning, is also well marked in Major's case.

Major regards the absence of any increase in the plasma chlorides
in the presence of an extensive tubular nephritis as evidence in favor
of the excretion of these substances by the glomeruli.

In a much more comprehensive study of the above described "urea
concentration test," Rabinowitch3 reports the results of his observations
with "this new" urea concentration test. The work was planned in
order "to determine its value as compared with the routine methods
now in use. No choice was made of the cases clinically. These were
studied as they were admitted to the wards and included marked
cardiac, cardio-renal and marked renal cases and those cases admitted
for other clinical pictures but which were also found to have
albuminuria." There are 50 cases presented. The results do not
confirm the statements of Weiss and Funk as regards " a marked parallel-
ism" between "the urea concentration test and McLean and the
phthalein elimination" although in a very rough way this is borne out
by Rabinowitch's work. This author also calls attention to the fact
that the urea concentration test is simply a duplication of the nitrogen
concentration in the urine as determined in the routine procedure of the
Mosenthal test-day. The results of the urea concentration test were
remarkably parallel to the nitrogen concentration in the night urine of

1 Progressive Medicine, 1921.

2 Johns Hopkins Hospital Bulletin, February, 1922, No. 3721, 33, 56.

3 Archives of Internal Medicine, December, 1921, No. 6, 28, 827.

CLINICAL AND FUNCTIONAL DATA

135

the MosenthaJ test-day. How valueless both these tests may be in a
given ease is shown by Rabinowitch. In 1 case, that of a woman
suffering from acute nephritis, with much albumin, easts, and red cells
in the urine, the functional tests showed no impairment throughout the
course of the patient's hospital stay while the nitrogen and urea con-
centration showed definite diminution; this diminution persisted even
at the time she was discharged from the hospital clinically improved.

This author also presents a table showing the routine functional tests
employed by him in the Montreal General Hospital for estimating
kidney function.

ROUTINE ADOPTED FOR ESTIMATING KIDNEY FUNCTION.

Clinical conditions.

Hypertension

Suspected early nephritis .

Acute nephritis

All edemas

Surgical kidneys (preoperative)
Prostatic enlargement (preopera-
tive)

Cardiac cases (for diagnosis) .
Cardiac cases (for progress)

Examination.1

NPN BU BCr UrAc NCI PST RTM NU AUT DIO

"Judging from our experience with this routine laboratory procedure,
we cannot help but conclude that there is no one single test for kidney
function, which, employed to the exclusion of all others, has not its
limited sphere of usefulness. It may reveal a fraction of the cause of the
clinical symptoms, and a very valuable one, but at its best, it is only a
laboratory aid, and must be correlated with the clinical picture in order
to reach a final diagnosis, which latter has justly been called "a complex
clinical judgment." The reason for this seems quite obvious. The
study of a pathologic reaction is the study of a disturbed physiologic
reaction, and the exact physiology of the kidney is still obscure."

Renal function, as expressed by the concentration of urea for 100 cc
of blood or when taken as part of one of the various formulae designed
to express the amount of excretion, has also received the attention of
several investigators — the work of Austin, Stillman, and Van Slyke
as described in Progressive Medicine, 1921, furnished the basis of
some observations made by Loveland and Hitchcock.2 The authors
have made use of the Austin, Stillman, Van Slyke index of urea excretion
to measure renal function in a group of 27 cases some with, and some

1 Explanation of abbreviations: NPN, non-protein, nitrogen of the blood; BU,
blood urea; BCr, blood creatinin; UrAc, blood uric acid; NCI, actual, calculated and
threshold of blood chlorides; PST, phenolsulphonephthalein; RM, Mosenthal renal
test meal; NU, night urine; AUT, urea concentration test (McLean and de Wesse-
low) ; DIO, daily intake and output of fluids.

2 Johns Hopkins Hospital Bulletin, 1922, No. 378, 33, 294.

136 GEYELIN: NEPHRITIS

without, evidence of nephritis. Of these cases, there are 7 who were
diagnosed either as nephritis or cardio-renal disease. The other cases
were suffering from a variety of diseases such as pernicious anemia,
serum sickness, tabes dorsalis, neurasthenia, and so forth. In addition
to the urinary analysis, the following functional tests and clinical find-
ings were studied in conjunction with the Austin, Stillman, Van Slyke
index for urea excretion, the phthalein test, blood-pressure determina-
tions, eye-ground examinations, urea nitrogen and non-protein nitrogen
of the blood. The protocols published do little more than suggest that
the above-mentioned index "may be of value in demonstrating renal
insufficiency and particularly in border-line cases." The authors find
that there are other conditions, such as hypertension with no evidence
of renal disease and no impairment of other functional tests who give a
strikingly low reading in terms of the index. This low reading wras also
found quite consistently in cases of pernicious anemia. Depressed
renal function (as shown by other functional tests) has also been observed
by Mosenthal, Christian and others in pernicious anemia.

This wrork is inconclusive in that it fails to show any striking advantage
gained from applying this particular index of urea excretion as a measure
of renal function, or in detecting early functional impairment when
compared with other functional tests.

That the urea test of Austin, Stillman, and Van Slyke is a definite
addition to our armamentarium of functional tests is indicated by the
following conclusions drawn by the above-named authors in data
as yet unpublished. (Austin, Stillman and Van Slyke — oral com-
munication.)

They conclude that there is a striking parallelism between the values
found by means of this test and the values found in the phthalein test
in all forms of nephritis and particularly in those cases when high
phthalein values are found, (so-called "irritative" stage).

This test also is apt to be found normal in certain cases wThen the blood
urea is high, but when the clinical picture, the other functional tests
and the subsequent course of the case indicate that the high blood urea
is not evidence of corresponding renal impairment.

The high normal or normal figures of Hitchcock in cases with other
evidence of slight renal impairment are in all probability thus explained.

It seems to me that the best method of approach to the problem of
"what is the value of a given functional test as regards its value in
detecting early renal disease" is to observe the course of renal disease
and its effect upon a given group of functional tests in suspected cases,
of nephritis at an early stage, wyith subsequent similar and systematic
observations as the disease progresses. When this has been done in a
large and carefully controlled group of cases, then and only then will
we learn to appreciate the full value of any given test for renal function.
Certain observers have claimed that an elevation of the blood uric acid
is the earliest evidence of beginning impairment of renal function, such
statements, in the light of our present knowledge, must remain as expres-
sions of individual opinion. In the first place, the normal range of
blood uric acid has never been definitely determined, and in the second

CLINICAL AND FUNCTIONAL DATA 137

place we do not know what other clinical conditions may, or may not
be characterized by transient or permanent increases in uric acid.

Ever since 1913 Addis and his coworkers have been working upon a
renal functional test which, according to Addis, would l>est serve as "an
indirect measure of the amount of secreting tissue present" in cases of
chronic nephritis

This work has dealt almost entirely with an attempt to formulate
laws which would govern conditions of the rate of urea excretion under
functional strain. Numerous papers have appeared from Addis's
Clinic in the past nine years — some of them having been reviewed in
Progressive Medicine, 1920 and 1921.

In his article in the California State Journal I of Medicine, March, 1922,
the author has finally adopted a test for measuring the urea functional
capacity of normal and pathologic kidneys — his opinions concerning its
usefulness and the details of technic are given in his own words.

"The blood urea concentration is first determined in order to find how
much urea will have to be given. If, as often happens even in fairly
tar advanced cases of Bright's disease, there is no increase in the amount
of urea in the blood the patient is given 30 grams of urea, or 20, 15, 10
or 5 grams, depending on the degree of urea retention which may be
present. If the urea concentration in the blood is over 75 mgs. per 100
cc, no urea need be given. At 6 a.m. next morning the patient slowly
drinks a quart of water in which the required amount of urea has been
dissolved, and every hour thereafter drinks twro glasses of water. No
breakfast may be taken, since protein food has a marked effect on the
rate of urea excretion quite apart from its effect on the blood urea con-
eoncentration. By 9 a.m. the apex of the curve of the raised blood urea
concentration is passed and during the next three hours it falls slowly.
This is the time during which three accurately-timed urine collections
are made, and the level of the curve of blood urea concentration deter-
mined by analyzing three samples of blood drawn in the middle of each
of the three periods over which the rate of urea excretion is measured.
From these the rates of urea excretion per hour are calculated and
divided by the amounts of urea found in 100 cc of the blood obtained
in the middle of each period. In the same individual under these
conditions this ratio remains nearly constant.

"In different normal individuals there are constant individual differ-
ences. The average ratio for normal individuals is approximately 50
— i. e., there is 50 times more urea excreted in one hour's urine than is
found in 100 cc of blood removed while the urea is being excreted. This
is independent of the actual level of blood urea concentration. We
have a large number of observations of normal individuals, but we are
still collecting further data, and it will be some time before it will be
possible to determine the probable error of the ratio in normals. We
have a series of observations on patients on whom the blood urea con-
centration and the phenosulphonephthalein test gave normal results,
who yet gave ratios below the lower limit of normal variation. In
such cases we believe that the degree of depression of the ratio measures
in an approximate manner the degree of destruction of the actively

138 GEYELIN: NEPHRITIS

secreting renal tissue. We believe that from these functional results
we are justified in drawing conclusions as to the extent of the patho-
logic process in the kidney."

Pericarditis in Nephritis. In an important study on the incidence
and nature of pericarditis with effusion in chronic nephritis, Barach1
shows that if all the reliable observations found in the literature are
taken into consideration the incidence of pericardial effusion at some
stage during the course of chronic nephritis is about 8 to 10 per cent.
Among all the cases of pericarditis, nephritis ranks third as an etiologic
factor.

The author has also studied the etiology of pericarditis in chronic
nephritis. The clinical and laboratory characteristics of a group of
30 cases of chronic nephritis at the time of development of an acute
pericarditis showed that the complication occurred in the nitrogen
retention type of nephritis, with marked elevation of the blood urea,
acidosis, hypertension, severe anemia, and a hemorrhagic tendency as
conspicuous features. A comparison of the bacteriologic with the
pathologic findings suggested a division of the cases etiologically into
two groups, infectious and non-infectious. In the first group pyogenic
infection of the pericardium wTas demonstrated by direct culture, and
was accompanied by a cellular infiltration predominantly of poly-
nuclear type. In the second group the pericardium was sterile on
culture and showed histologically either mononuclear infiltration or no
infiltration whatsoever. The chemical nature of the toxemia lends
corroborative evidence of the existence of a chemical irritant as cause of
the acute pericarditis of the second group: It appeared from the
pathology that the majority of cases of pericarditis occurring in chronic
nephritis were of non-infectious origin. In the smaller group in which
frank infection of the pericardium is found the possibility is present
that the infection may have become lodged upon a pericardium pre-
viously inflamed through a chemical or non-infectious agent.

The" striking feature of Barach's work which makes it a very valuable
contribution, is the completeness and extensiveness with which the cases
were studied.

Pathology. Another attempt at classifying renal disease chiefly
from an anatomic basis is offered by Bell and Hartzell in a somewhat
lengthy paper. As far as one can gather from the text, the material
presented is based upon the microscopic findings in the kidneys of
3300 consecutive autopsies. The authors do not make it clear how
many of these cases w^ere considered to have had nephritis— brief and
in most instances inadequate case histories, together with clinical
findings and a description of microscopic kidney morphology are pre-
sented in 69 cases of nephritis. These cases all showed more or less
glomerulonephritis .

The authors announce in their opening paragraph, that " there are
four well-established types of renal disease that must be considered in a
discussion of nephritis." These four types with their subdivisions are as
follows :

1 American Journal of the Medical Sciences, January, 1922, No. 1, 163, 44.

PATHOLOGY OF NEPHRITIS 139

I. Pyelonephritis.

(a) Acute interstitial nephritis seen most commonly in scarlet fever
"is related to this group in that it is an exudative inflammation of the
interstitial tissues."

(b) "Spontaneous chronic nephritis" of laboratory animals is claimed
to be "more closely related to pyelonephritis than to any other form of
human renal disease." Both these forms of nephritis seem to be types
of pyelonephritis, according to Hartzell and Bell.

II. Nephrosis.

"This group is not sharply separable from glomerulonephritis since
cases of degeneration occur in which it is very difficult to determine
whether there are any reactive changes in the glomeruli."

Nephrosis, according to Bell and Hartzell, is a " term applied to renal
lesions of a degenerative character in contrast to nephritis in which the
phenomena of reaction (exudation, proliferative) have appeared."

The authors also make the statement that "nephrosis is by far the
commonest form of renal disease seen at necropsy." They also add that
they did not encounter any cases of chronic nephrosis in their necropsy
material similar to the types seen by Volhard and Fahr, cases of this
type having been designated by Volhard and Fahr as "genuine" neph-
rosis. This is probably the same type of nephrosis upon which Epstein
has laid so much emphasis and which is spoken of by him as a metabolic
disease. See Progressive Medicine, 1921.

III. Arteriosclerosis of the Kidneys.
(a) Senile type.

(6) Hypertension type.

It is admitted that the arteriosclerotic type of renal disease is "not
sharply separable from" glomerulonephritis, but Bell and Hartzell
believe that there is " no justification for the view that the two diseases
are indistinguishable" as Moschcowitz claims.

IV. Glomerulonephritis.

(a) Acute.

(b) Subacute.

The clinical records of microscopic findings alluded to above in 69
cases are apparently all taken from this fourth group. After a careful
study of the subject, clinical and microscopic data, we are unable to
find that the authors make any important distinction between acute
glomerulonephritis of Group IV and the acute interstitial nephritis of
Group I except that, according to Bell and Hartzell, acute interstitial
nephritis frequently occurs in scarlet fever and rarely in other infections,
whereas acute glomerulonephritis usually occurs with other infections,
such as infections with streptococci.

The belief is held by these authors that all cases of acute glomeru-
lonephritis are most probably of infectious origin — this is also the belief
of the vast majority of observers and the microscopic findings in such
kidneys at autopsy would confirm this view in spite of the fact that
bacteria cannot be found in the glomerular endothelium — an observation
made by Ophuls and others.

140 CEYELIN: NEPHRITIS

The etiology of subacute glomerulonephritis is discussed in con-
junction with that of chronic glomerulonephritis (according to the
authors a case of the former becomes chronic when the duration of the
disease has exceeded one year), the evidence deduced by Bell and
Hartzell is in favor of the assumption that chronic glomerulonephritis
probably owes its origin to an infection (clinically marked) and that
repeated exacerbations of acute glomerulonephritis give to the chronic
form of the disease its progressive nature. The authors' summary of
the evidence presented and the conclusions and hypotheses derived
therefrom are given verbatim:

" Thirty-two cases of acute glomerulonephritis have been studied. In
many of these cases death was due to extrarenal causes and early
glomerular lesions are available for study.

"Degenerative, exudative and proliferative types of inflammation
occur in the glomeruli. Proliferative changes are chiefly responsible
for permanent glomerular damage.

"Acute glomerulonephritis is nearly always due to some acute infec-
tious process, usually a streptococcal infection. The bacteria gain access
to the blood and it is probable that the injury is produced by the
direct action of their bodies on the glomerular endothelium.

"An occasional case of acute glomerulonephritis passes into the
chronic form; but the great majority of chronic cases do not begin as
frankly acute nephritis.

"Acute glomerulonephritis is linked with the chronic form by numer-
ous intermediate cases.

"Glomerular lesions in chronic kidneys correspond to healing or healed
stages of acute glomerulitis. Old epithelial crescents are common,
and disintegrating polymorphonuclear leukocytes are frequently found
in the closed glomerular capillaries and in the partially atrophied tubules.
In a few chronic cases acute and subacute glomerular lesions were found,
indicating acute exacerabations.

"In chronic glomerulonephritis many glomeruli are obliterated com-
pletely and those persisting show permanent closure of a part of the
capillary network. Function is carried on by damaged glomeruli, and
is depressed not only because of reduction in the total number but also
because of the reduced capillary network in those that persist.

"The progressive nature of chronic glomerulonephritis is apparently
due, in part, to repeated acute exacerbations.

"All forms of glomerulonephritis are due directly to bacterial invasion
of the glomeruli ; and the various clinical and pathologic types depend on
the degree and extent of the permanent glomerular injury."

The theory of the infectious origin of nephritis alluded to in the work
of Bell and Hartzell above is further emphasized by Emerson1 and his
coworkers. This author believes "that in chronic nephritis there
usually are two processes to consider: 1, The chronic, that is the
permanent element, the epithelial cell proliferation and the scar tissue
formation, both of which are evidences of healing. 2, An acute

1 The Acute Element in the Chronic Nephropathies, Journal of the American
Medical Association, 1921, 77, 744.

RENAL PHYSIOLOGY 141

injurious clement of the nature of a definite acute nephritis which
perpetuates the disease and indirectly increases the permanent lesion."
Although in the above quotation there is no specific mention of acute
infections, the author obviously believes that the acute exacerbation
so often repeated in the course of chronic nephritis and which are
usually accompanied by fever, represent the effect upon the kidney of
infectious processes elsewhere in the body. Emerson has made a careful
study of the course of events in many cases of chronic progressive
nephritis and draws attention to the fact that there are intermittent
periods lasting for several days or weeks where the patient develops
slight or marked febrile reactions succeeded by periods of normal
temperature. During these febrile periods many of the functional tests
are diminished and the urine very frequently shows an increased amount
of albumin and red blood cells. In each succeeding period with normal
temperature although the albumin and red blood cells may disappear
or are much diminished, the renal function tests, although they may
regain their position on a higher level than during the febrile period,
show a steady downward tendency if succeeding afebrile periods are
contrasted one with another. Emerson concludes that these findings
demonstrate the fact that no stone should be left unturned in seeking
hidden foci of infection and of controlling dietary factors which may have
an influence on the downward progress of the disease. Ritchey,1 working
in Emerson's clinic, presents the complete statistics upon which the
foregoing conclusions are based. He reports 24 cases of acute nephritis
22 of whom showed fever, 25 cases of chronic parenchymatous nephritis
16 of these showed fever, 110 cases of chronic interstitial nephritis, 77
having had temperature at some stage of the disease. Ritchey draws
the following definite conclusions: (1) During febrile elevation in the
course of chronic nephritis due either to infection or to some other agent
there is noticeable and measurable depression of renal function. (2) A
great majority of all cases of chronic nephritis showed a temperature
at some time during their course. (3) That fever with an increase of
albuminuria shows an added acute process.

These studies of Emerson and Ritchey are particularly interesting
because of their extensiveness and because of the new light they cast
upon the picture of renal disease studied carefully over a long period of
time. Febrile reactions should undoubtedly be more carefully and more
frequently observed.

Physiology. A most important piece of work by Richards, on renal
physiology, briefly alluded to in Progressive Medicine, 1921, was
presented injone of the Harvey Society lectures in 1921 — and reprinted
in the American Journal of the Medical Sciences in January, 1922.

This work is analogous in its importance to the work of Krogh on
capillary circulation and is the most valuable contribution to our
knowledge of renal physiology that has appeared in the past twenty
years.

The author outlines in a clear and consecutive manner the history

1 American Journal of the Medical Sciences, June, 1922, 163, 882.

142 GEYELIN: NEPHRITIS

of the development of the so-called glomerular filtration and tubular
resorption theory of normal renal physiology. He emphasized the fact
that the preponderance of experimental evidence is in favor of this
explanation of the mode of urinary secretion. The only evidence which
would seem to contradict the above hypothesis is the work of Heiden-
heim who showed that, by partial or complete occlusion of the renal
veins, urinary secretion could be materially lessened or wholly
suppressed. This fact, according to Heidenheim and others, refuted
the theory that urinary secretion (at least that part of it that was
concerned with the excretion of water and salts) was explained on the
basis of glomerular filtration. Richards himself admits that Heiden-
ham's observations constituted strong evidence against the filtration
theory.

Richards draws attention to the fact that there must be three import-
ant factors all of them variable, which might influence filtration through
the glomeruli. (1) Rate of blood flow through the kidney. (2) Amount
of blood passing through the kidney. (3) Pressure of blood in the
kidney. Previous investigators had recognized these factors but had not
attempted to control any two of them with the idea in mind of studying
the effect of such control upon experimental conditions designed to pro-
duce variations in the third. Richards, however, was able to devise a
perfusion apparatus whereby arterial blood could be constantly passed
through the renal artery under conditions which enabled him to keep
the rate of blood flow and the amount of blood constant. He was then
able to vary the blood-pressure in the perfused kidney by three methods :
(1) Stimulation of the splanchnic nerve. (2) Injection of adrenalin.
(3) Partial occlusion of the renal vein. Since all of these agencies
raised pressure in the renal circulation, and since the conditions of the
experiment were such that the rate of blood flow and amount of blood
flow per unit of time were not materially affected, it seemed reasonable
to conclude that the results observed were due to change in the renal
blood-pressure. Each of the three agencies used increased urine forma-
tion in every instance.

Upon this evidence Richards believes that he is able to refute the
objections raised by Heidenheim because, in Heidenheim's work, when
no attempt was made to control volume and rate of blood flow the
suppression of urine was probably due to the stagnation of blood in the
glomeruli thereby increasing osmotic resistance which could not be
overcome by increase in pressure alone. In other words, Richards has
shown that the identical procedure employed by Heidenheim to raise
blood-pressure within the kidneys, i. e., partial venous occlusion, will
not decrease the urinary output but will, on the contrary, increase
urinary output provided the rate and volume of blood flow is kept at a
constant level.

Richards work thus seems to remove the last valid objection to the
belief that secretion by the glomeruli is explicable on the hypothesis of
filtration.

The second important contribution made by Richard is the result of
observations made upon the glomeruli of the frogs' kidney in vivo. By

RENAL PHYSIOLOGY 143

a very ingenious method lie was able to observe certain groups of
glomeruli under the microscope and study the effect upon their phy-
siology of various well recognized diuretic and vasoconstricting sub-
stances. The net result of these observations is that contrary to the
conception of uniform rate and quantity of blood flow through all
glomeruli at the same time Richards has been able to establish the fact
that only a limited number of glomeruli are active or receiving blood
at any given moment while the remainder are at rest and receiving
relatively little blood. Any diuretic influence will greatly increase the
number of "active " glomeruli in a given microscopic field while any vaso-
constricting influence will greatly diminish the number of active
glomeruli.

The length of time during which a given glomerulus may "intermit"
or cease to be active is very variable and is not related to the rate of the
heart.

Folin1 reviews the development of our knowledge of the physiology
of non-protein nitrogen of the blood in health and disease and inciden-
tally shows what important contributions have been made to our more
recent knowledge by the American school of physiologic chemists.

The non-protein nitrogen of blood filtrates after precipitation of the
albuminous material by one or another of the protein precipitants,
show that a considerable variation exists in the distribution of the
individual non-protein constituents and in their total amounts. These
variations, depending upon which of the many protein precipitants is
used. This fact according to Folin would seem to indicate that there
are some nitrogenous products which are partly thrown down with the
coagulable protein and partly escape precipitation.

Folin says that the products obtained in blood filtrates may be
classified in three groups:

"A. Nitrogenous waste products."

"B. Absorbed nitrogenous food material."

"C. Undetermined materials including some undetermined absorbed
food products and in addition some products of unknown origin."

"It is important that the clinician should have certain definite knowl-
edge regarding the amount of the various non-protein nitrogenous
constituents found in normal blood. This information Folin has
brought up to date after critical consideration of all the published data
and the variations in chemical procedures with which these data have
been compiled.

"The normal variations of the urea nitrogen lie between 8 mgm. and
15 mgm. per 100 cc of whole blood. The latter figure is really outside
the normal, unless the subject is on a very high level of protein metabo-
lism. In connection with upper normal values, it should be pointed out
that these values may persist for two or three days or longer after the
protein consumption has been reduced. A low normal level is, there-
fore, not necessarily obtained, because the blood is taken before break-
fast in the morning.

1 Physiological Reviews, July, 1922, No. 3, vol. 11.

144 GEY ELI N : NEPHRITIS

"As a part of the total non-protein nitrogen of human blood the urea
nitrogen varies under normal conditions between 35 and 55 per cent.
The proportion falls most frequently between 40 and 50 per cent, but
the variations are so large that it is not safe to assume, as is frequently
done, that the urea nitrogen is just about one-half of the total non-
protein nitrogen. In nephritic nitrogen retentions, the increase usually
involves a greater increase of the urea than of the total nitrogen, and the
per cent of the latter represented by urea may rise up to 70 per cent.

"Since the introduction of the urease methods for the estimation of
urea, this determination has become the most popular in chemical
laboratories. The determination is unfortunately by no means so
dependable as many seem to think. The enzyme employed is exceed-
ingly sensitive, is occasionally more or less completely inactivated, and
yields values that are too low. The total non-protein nitrogen deter-
mination represents, therefore, a more valuable and more dependable
process for the study of nitrogen retention than does the urea determina-
tion. Both normally and in nitrogen retentions the urea is more
abundant in the plasma than in the corpuscles."

Commenting upon the use of simultaneous determinations of urea in
the urine and in the blood as a means of determining the excretory
efficiency of the kidneys, Folin makes the following statement.

"Opinions differ as to the values of such studies. The fundamental
underlying assumption that the excretory power of the kidneys may be
expressed in the form of a dependable constant is none too well estab-
lished, however alluring it may appear to those who like to express
metabolism processes in terms of mathematical formulas. The idea
of the existence of such a constant certainly breaks down when it is
extended so as to account for the rate of excretion of all waste products."

In setting forth the normal range of uric acid in human blood, Folin
avoids making a definite statement. His summary is as follows:

"In the normal human blood the uric acid content is subject to
relatively greater variations than that of any other known nitrogenous
product. The lowest figure reported by Folin and Denis is 0.7 mgm.,
and the lowest found by Benedict out of 50 analyses is 0.8 mgm. The
maximum normal figure for the uric acid may perhaps be given as 3 mgm.
per 100 cc."

Creatinin content of normal blood is given as 1.2 to 1.5 mgm. per
100 cc of blood while creatin values normally range from 3.5 to 5 mgm.
per 100 cc of blood, although by very recent work Behr and Benedict1
claim that there is less than 0.05 mgm. of creatinin in normal and that
only creatine is present. Folin predicts that this finding "will not long
remain without contradiction or verification."

The amount of amino-acid nitrogen found in normal human blood,
according to Folin, ranges from 5.7 to 7.8 mg. of nitrogen per 100 cc of
blood.

Increases in amino-nitrogen content of blood corresponding to
increases of non-protein nitrogen, as seen in nephritis, for the most
part do not occur and are very variable when they are found.
1 Journal of Biological Chemistry, 1922, 52, 11.

RENAL PHYSIOLOGY 145

The question of the influence of arterial hypertension in producing
nephritis has given rise to much controversy. The prevailing view at
present is that patients suffering from arterial hypertension may without
any clinical or functional evidence of nephritis in many instances become
definite eases of nephritis. Many other eases develop eardiac vascular
disease with subsequent eardiae insufficiency as the predominating
clinical picture. Still another group of patients with arterial hyper-
tension develop evidence of extensive changes in their cerebral arteries.
Clinically, many physicians advocate the use of increased water drinking
in patients where high blood-pressure is the only presenting symptom;
that this procedure may have some value in offsetting the progressive
character of arterial hypertension is suggested by the work of Orr and
Innes1 who have investigated the influence on protein metabolism of
a sudden increase of the amount of water passing through the system
suggest that the increased ingestion of water affects the metabolism of
protein in such a way that the formation of pressor substances is reduced.
Experiments were carried out to determine what influence an increased
water intake has upon the blood-pressure. During a preliminary
control period of two or three days the normal amount of water was taken
and many systolic and diastolic readings were taken. Then for one or
more days a measured amount of water was taken at one time or at
intervals. On the following days the usual amount of water was taken.
Thus the experiments were divided into three periods, prewater, water
and postwater. Muscular exercise and emotional disturbances were
elimination as far as possible. The readings were taken after the
subject had been allowed to lie on a bed for fifteen minutes, with the
Riva-Rocci instrument. The experiments were conducted on healthy
subjects with normal blood-pressure, on subjects with blood-pressure
above normal but no kidney lesions and 14 pathologic cases with
markedly raised pressure. The results showed a decrease in blood-
pressure in the apparently normal subjects and in the pathologic cases
after ingestion of water. In the pathologic subjects there was a
tendency for the pulse to rise on the water days. In all the subjects the
pulse rate was slower after the ingestion of water. The fall in pressure
may be due to the elimination of pressure substances that cause arterial
constriction. These results are in agreement with Hay's original
observations.

It is suggested that three factors may be involved in the reduction of
blood-pressure noted in these experiments. The initial flushing-out
process, as evidenced by the increased excretion of nitrogen, may remove
pressor substances from the system. Fowler and Hawk's results
suggest that anaerobic disintegration of nitrogenous material in the
large intestines may be diminished, with a consequent reduction in the
formation and absorption of pressor substances. Substances producing
arterial contractions arise in sluggish or perverted metabolism or under
conditions of protein surfeit. The acceleration of the metabolism of
protein with the more rapid formation of innocuous final products
would lead to the elimination of these pressor substances.

1 British Journal of Experimental Pathology, April, 1922, p. 3961.

146 GEY ELI N : NEPHRITIS

Treatment of Nephritis. The great number and variety of thera-
peutic procedures which are advocated every year in the literature of
nephritis serve to illustrate how futile and unsatisfactory the treatment
of nephritis is in the vast majority of cases. There are certain com-
monly accepted procedures, such as salt restriction, fluid restriction,
protein restriction and the administration of certain diuretic substances
which are universally accepted and tried in most cases.

I am therefore not going to attempt to review all the various thera-
peutic suggestions of the past year, most of which are unimportant, but
will devote this space to the interesting observations of Blum1 and his
coworkers on the effect of certain calcium and potassium salts in
relieving edema, whether this edema be due to liver, kidney or cardiac
disease. The work of these authors has important bearing not only
upon the problem of the relief of general anasarca but also contributes
greatly to our knowledge of the fundamental physico-chemical condi-
tions underlying the production and relief of edema from any cause. .

Blum first became interested in this problem in 1910 in connection
with the edema so commonly observed in diabetes after the administra-
tion of large doses of sodium bicarbonate. He found that this type of
edema and also other types could be relieved by large doses of certain
salts of potassium — these salts seemed to greatly facilitate the excretion
of the sodium ion which was accompanied by a marked increase of water
excretion and loss of body weight. These results obtain for other salts
of potassium and also for certain salts of calcium. Blum has found that
calcium chloride is the salt of choice for all forms of edema — potassium
being contraindicated in cases of edema due to cardiac disease, while
calcium is without injurious effect upon this particular condition. The
dose of calcium chloride recommended is 25 gms. per day and may be
given with small amounts of sodium chloride or with a "salt-free diet."

The protocols given illustrating the water and weight loss in patients
suffering from many different forms of edema — (nephritic, cardiac and
hepatic) — are very convincing of the striking action of calcium and
potassium salts in abolishing edema.

What makes the effect of these salts all the more spectacular is the
fact that in most of the protocols submitted other diuretic procedures
had yielded no result in diminishing edema in spite of the fact that they
were carried out over long periods of time.

1 Extrait de La Presse Medicale (No. 70 du 29 Septembre, 1920) M. Leon Blum.
Extrait de Bulletins et Memoires de la Societe medicale des Hopitaux de Paris
(Seance du 29 Juillet, 1921) Mm. L. Blum, E. Aubel et R. Hausknecht. Extrait des
Bulletins et Memoires de la Societe medicale des Hopitaux de Paris (Seance du
Novembre 18, 1921), MM. Leon Blum, E. Aubel, et Robert Levy. Extrait de
Bulletins et Memoires de la Societe Medicale des Hopitaux de Paris (Stance du
25 Novembre, 1921), par Mm. Leon Blum, E. Aubel et R. Hausknecht.

GENITOURINARY DISEASES.

By CHARLES W. BONNEY, M.D.

DISEASES OF THE KIDNEYS AND URETER.

Some generalizations concerning renal surgery, with special reference
to the mortality rate and postoperative results, have been presented by
John R. Caulk1 in an analysis of 2G3 cases which came under his care.
This is a paper which may be read with profit by all general practi-
tioners, for the author clearly points out the significance of symptoms
in the early stages of surgical renal disease and shows how their early
recognition, followed by appropriate treatment, will redound to the
benefit of the patient. He states that in his series there were some
operative cases in which symptoms had been present for four and one-
half years before the nature of the trouble had been recognized. An
early diagnosis in some of these cases would have obviated the necessity
for surgery.

One of the most important statements which the author makes, is
to the effect that if cystitis does not clear up after ten days of local
treatment, there is probably some associated condition which warrants
further investigation. Relief of retention within the pelvis of the kidney
by drainage through the ureteral catheter, lavage of the pelvis in
pyelitis, dilatation of ureteral stricture, and the removal of impacted
calculi by manipulation through the operating cystoscope are some of
the measures that were applicable in his case. Torsion of the ureter
has been cured by passage of the ureteral catheter a few times.

With regard to movable kidney, the opinion is expressed that a
proper fixation will practically always effect a cure. This statement,
it is assumed, refers only to those cases in which the misplacement is
producing symptoms directly referable to the urinary tract, and not to
those in which the misplaced kidney is associated with visceroptosis.
In fact, the author considers fixation of movable kidney, which is pro-
ducing urinary retention, the most important technical operation in
renal surgery.

In the author's series of cases, operations were performed for stone
by nephrectomy, nephrotomy, pyelotomy, and combined pyelotomy,
and nephrotomy; for tuberculosis of the kidney; tumor; movable kidneys
with intermittent hydronephrosis, large hydronephroses, hydronephritis
and perinephritic abscess and, finally, for nephritis, in which decapsula-
tion was done. There were 5 deaths in 263 operations. When discussing
the indications and preparatory treatment, the author states that the
heart, lungs and nervous system must be put in the best condition pos-

1 Journal of the American Medical Association, September 10, 1921.

148 BONNEY: GENITO-URINARY DISEASES

sible and that, except in emergency, no operation should ever be done
without adequate preparation. In the presence of infections, prepara-
tory drainage should be used. If there are renal calculi, infected hydro-
nephrosis or pyelonephritis, continuous drainage with the ureteral
catheter will bring about improvement. The patients should drink
large quantities of water, and urinary antiseptics, such as urotropin and
acid sodium phosphate, should be given. In septic cases, as well as
those in which the hemoglobin is low, transfusion may be resorted to
with benefit. The Murphy drip may be advantageously used before
operation as well as after. A mixture of gas and oxygen is considered
the best anesthetic, though sometimes it will have to be supplemented
by a little ether. After operations for stones, the author always instills
the pelvis with silver nitrate solution in order to overcome infections
and stimulate granulations. This is done during convalescence by
means of an injection through the ureteral catheter.

In a report upon the material from Martynoff's clinic in Moscow,
the accidents occurring in association with nephrectomy are discussed by
Fronstein.1 One of the most frequent injuries was opening of the
peritoneum. When immediately sutured, usually no complications
followed, although in 2 cases of secondary nephrectomy for renal fistula
a fatal peritonitis resulted from the accident. When breaking up ad-
hesions between the colon and kidney in chronic inflammatory conditions,
there is some danger of producing a fecal fistula, and in some such cases
the author considers it better to perform a resection of the bowel than
to traumatize it by a prolonged effort to free it from the kidney. _ In 1
case of renal tumor involving the cecum, Martynoff removed the kidney,
resected the cecum and then made a transverse anastomosis between
the ileum and the colon. In 1 case gangrene of the bowel followed
nephrectomy. It was, however, attributed solely to the haste and
roughness of the assistant, who made very hard pressure upon the
abdominal wall in order to facilitate delivery of the kidney through the
lumbar incision. Hemorrhage from the bowel was not noted in any of
Martynoff's cases, although in a series of 206 kidney operations in
Fedoroff's clinic in St. Petersburg the author states he is informed that
it occurred 4 times. This complication is attributed to thrombosis
of the mesenteric veins. Injuries to the pleura are not uncommon and
are frequently followed by pneumothorax and empyema unless the
tear is immediately repaired. When immediate closure is made, there
are usually no bad effects. Hemorrhage is considered the most danger-
ous complication. It may result from injury to normal or supernumer-
ary renal vessels and also from injury to the vena cava and the iliac
artery. In Martynoff's clinic, mass ligation of the renal pedicle is never
practised, the component parts being carefully separated and the arte-
ries, veins and ureter individually ligated. It is not considered safe to
leave a clamp on the pedicle. In a search through the literature, Fron-
stein found a record of 25 cases in which the vena cava was torn; in 12,
the patients recovered; in 13, they died. As a rare complication, reflux

1 Nautschnaja med., 1921, 1, No. 8.

DISEASES OF THE KIDNEYS AND URETER 149

of the urine from the bladder into the remaining portion of the ureter
is mentioned. A more common sequel was suppuration in the ureteral
stump, especially in cases of pyonephrosis. One such case is mentioned
in which 3 operations were necessary to effect a cure. In last year's
review the methods of dealing with the ureter in renal tuberculosis were
fully discussed. In this connection it is interesting to note that Marty-
noff does not favor an extensive removal of the ureter, his rule being to
remove as much as can be easily liberated through the usual lumbar
incision. lie crushes, doubly ligates with catgut and then divides with
the thermocautery. One death from anuria followed nephrectomy in
a case iri which the other kidney responded well to a number of functional
tests. Anuria developed in another patient whose kidney had been
removed under morphine-ether anesthesia. Thirty-nine hours after its
onset, renal decapsulation was performed, but death occurred sixteen
hours later. Autopsy revealed an acute parenchymatous nephritis.

In the Hunterian Lecture delivered at the Royal College of Surgeons
this year, hydronephrosis was fully discussed by Charles A. Pannett,1
who, at the beginning of his lecture, stated that his object was to arrive
at a truer conception of the genesis of upper urinary retentions, to
review modern methods of recognizing them in their early stages, and
to describe the various forms of treatment.

The usual causes of retention within the pelvis of the kidney include
narrowing at the ureteral pelvic junction, displacement of the kidney
causing kinking of the ureter, calculus impacted in the ureteropelvic
junction, stricture produced by the healing of an ulcer which such an
impacted calculus may cause, and, finally, periureteritis.

In addition to these commonly recognized causes, the author attrib-
utes considerable etiologic importance to spasm at the ureteropelvic
junction. A consideration of the salient facts of renal secretion and
discharge has led him to the conclusion that the renal pelvis and the
ureter possess decidedly different functional attributes. It is well
known that the passage of the urine dowm the renal tubules into the
pelvis of the kidney is continuous, and also that the discharge of urine
from the ureter into the bladder is intermittent. In view of these
phenomena the theory is advanced that the renal valves act as a tempo-
rary reservoir for the urine, being separated from the ureter by muscular
contraction at the ureteropelvic junction. At certain intervals the
pelvis contracts and with this contraction there is a relaxation at the
ureteropelvic junction, as the result of which urine passes into the
ureter and is carried onward by peristalsis. A number of experiments
are cited to substantiate this theory; and, furthermore, cases of hydro-
nephrosis are cited in which, at operation, a fair sized catheter could be
passed downward through the ureter without meeting any obstruction,
the pelvis of the kidney alone being distended. Whether such spasm is
due to irritation of the kidney or pelvic wall, as, for instance, by some
change in the composition of the urine, or to extrinsic nervous reflex,
the author is unable to decide.

1 British Journal of Surgery, April, 1922.

150 BONNEY : GENITO-URINARY DISEASES

Pannet believes that the frequency of congenital valves at the upper
ureteric aperture has been overestimated and that they are probably
a very rare cause of hydronephrosis. He points out, however, that a
congenital valve must not be confused with a secondary valve which
forms as the result of the hydronephrosis itself. He is also inclined to
attribute very little etiologic importance to abnormal polar vessels.

With regard to the latter opinion space may be taken to note that
R. H. Kummer1 has collected more than 50 cases in which hydronephrosis
was apparently due to the presence of an obstructing abnormal renal
vessel. He also reports 3 from Marrion's clinic in Paris.

In the reviewer's mind no doubt exists as to the positive etiologic role
of abnormal renal arteries situated at the lower pole.

Clinically, unless the condition is so far advanced that a renal tumor
is formed, there will be no symptoms sufficiently characteristic to
enable a surgeon to do more than suspect the presence of beginning
dilatation of the renal pelvis. The pain is such in character and location
that it may lead one to believe that the trouble is situated outside the
urinary system. The urinary findings are also very inconstant, and
may even be absent in a considerable number of cases. Cystoscopy,
with ureteral catherization and pyelography, will make the diagnosis
clear. The changes brought about by distention are minutely described,
and the methods of technic and interpretation of the pyelograms are
also fully explained.

In the choice of treatment lying between nephrectomy and some
measure by which the kidney may be conserved, it is essential to deter-
mine two things: (1) The existence of another healthy kidney, and
(2) the functional power of the diseased kidney. The first is established
by cystoscopy. x\ecompanving every hydronephrosis there is always
some chronic interstitial nephritis and failure of renal function. Natu-
rally, the functional renal tests will be of some value in obtaining an
answer to the second question, but the author expresses the opinion
that neither the determination of the urea debit nor the elimination of
phenolsulphonephthalein furnish absolute indications for a radical or a
conservative operation. He cites the experience derived from treating
cases of prostatic hypertrophy by preliminary drainage of the bladder,
explaining how the functional power of the kidneys will frequently show
marked improvement after back pressure has been relieved by vesical
drainage. In hydronephrosis visual estimation of the amount of renal
tissue remaining, as determined at operation, will afford a more accurate
guide than preliminary functional tests. Braasch is quoted to the
effect that when the hydronephrosis contains more than 150 cc, very
little secretory tissue remains.

During a period of three years 15 cases came under the author's
observation. Out of this number nephrectomy was necessary in 4— on
account of extensive distention and destruction of kidney substance.
Another nephrectomy was done to remove an obstructing tumor.
Nephropexy was performed three times, pyelotomy for stone twice,

1 Journal d'Urologie, June, 1922.

DISEASES OF THE KIDNEYS AND URETER 151

pyeloplication once and ureteropyeloplasty three times. One patient
was not operated upon.

The decision to perform a plastic operation having been reached,
the question arises whether by removing the hindrance at the upper
end of the ureter, conditions will be rendered such that the dilated
pelvis will shrink and recover its normal function. In view of well-
known physiologic facts, the author believes that such will not prove
to be the case unless the pelvis is emptied at operation and kept empty
by drainage for a considerable time. If the pelvis be made smaller by
resection, return to normal may perhaps be facilitated. However, it is
considered better to employ drainage as a matter of routine.

The following opinions concerning the different surgical procedures are
expressed: Nephropexy is considered the proper surgical treatment
for cases of physiologic obstruction accompanied by abnormal mobility.
A small tube should be used for draining the renal pelvis. It emerges
from the wound made for the passage of bougies dowai the ureter.
Nephropexy should also be performed when any plastic operation has
been done on the renal pelvis.

Ureteropyeloplasty is thought to be the best operation when there
is a congenital stricture and the wall of the ureter is not inflamed or
fibrosed. Pelvic drainage must be provided by special incision. This
plastic operation may be advantageously combined with resection of
the lower part of the pelvis. Should the insertion of the ureter be very
high, reimplantation of the ureter, or lateral anastomosis, is necessary.
When the upper part of the ureter is obliterated by disease, drainage is
necessary. Lateral anastomosis of the ureter to the lowest part of the
pelvis is considered preferable, for it preserves muscular continuity
between the pelvis and ureter, whereby the coordination of pelvic con-
traction with ureteric peristalsis is uninterrupted.

Pyeloplication and pelvic resection are indicated when the ureteric
orifice is of good size, but situated high; and division of a secondary
valve is also very satisfactory.

Reviewing the results of these different plastic operations, it may be
stated that there is a very fair prospect of preserving the function of
hydronephrotic kidneys by their aid. When it is remembered that
many excellent results were obtained at a time when diagnosis could
only be made by the palpation of a tumor and the condition was neces-
sarily advanced, it will be understood that with our modern methods
of diagnosis the outlook for the future is much brighter.

The Indications and Technic for Nephroureterectomy form the subject of
an interesting paper on renal surgery from the pen of Edwin Beer,1 Mt.
Sinai Hospital, New York. The operation is recommended for the
following conditions; namely, tumors, special papillary growths, tubercu-
lous kidney with stricture of the lower ureter, and impacted stone in
the lower portion of the ureter associated with extensive hydronephrosis
and hydrometer.

The operation is performed as follows: The kidney and pelvis are

L Journal of the American Medical Association, October 8, 1921.

152 BONNEY: GEN I TO-URINARY DISEASES

freed from the vascular pedicle, which is ligated, and the ureter is then
separated by blunt dissection as far as the fingers can reach, usually
to about the level at which the iliac vessels cross it. Then it is ligated
and the suture is left uncut so that it may be used for traction later in
the operation. Through a second incision at the outer border of the
rectus muscle, the ureter can be identified by intermittent traction
made upon the suture. It is gradually freed, the dissection being
carried down to the bladder, and finally is doubly ligated and divided
with the cautery-point or a knife dipped in carbolic acid. The last
stage of removal consists in bringing the kidney and ureter out through
the lumbar incision. The author believes that this method considerably
lessens the danger of opening the ureter or wounding the peritoneum,
and that it does not constitute an increased operative risk.

During the last few years decapsulation for nephritis has been dis-
cussed in this review on two occasions. A case sufficiently interesting
to warrant brief description here was recently reported by Xorris W.
Vaux.1 It was that of a boy, aged six years, suffering from chronic
nephritis. After all of the usual methods of treatment had been tried
without benefit, decapsulation of the right kidney was performed under
nitrous oxide and oxygen anesthesia. At the time of the operation the
child's condition seemed hopeless. Prompt improvement took place
after the operation and it was decided to decapsulate the left kidney.
Within a few weeks after the second operation the child was playing
about the ward and showed no signs of having been sick.

Renal Calculus. J. D. Barney2 has studied 139 cases of renal calculus,
which were treated at the Massachusetts General Hospital, and has
given special attention to the subject of recurring or overlooked
calculi. The number of patients in whom subsequent examination
showed the presence of one or more stones is surprisingly large. For
example, 50 per cent of those upon whom pyelotomy had been performed,
subsequently were found to have calculi remaining in some part of the
kidney. Of 20 patients who were examined with the roentgen rays during
convalescence, 9 showed stones. Seventy patients were treated by neph-
rotomy and more than one-half of them (52.9 per cent) were found to
have stones which either had been overlooked at the time of operation or
had reformed after operation. Barney's own experience with renal
calculus and his study of the experience of others at the institution at
which he is working, have convinced him that it is not always possible
to remove all stones from the kidney. He expresses the opinion, how-
ever, that the percentage of failures will be reduced in direct proportion
to the care that is taken before and during operation. Preoperative
study and localization of the stone-shadows are considered absolutely
necessary; and, if possible, a roentgen-ray examination should be made
on the day of the operation. The use of the fluoroscope during the
operation may also be of help.

Pyelotomy is considered adequate for the removal of small stones
even when a number are present. Nephrotomy is advised only when

1 New York Medical Journal, November 2, 1921.

2 Boston Medical and Surgical Journal, January 5, 1922.

DISEASES OF THE KIDNEYS AND URETER 153

the stone is of such size and shape as to make its extraction through
the renal pelvis impossible. In the author's own eases nephrectomy was
performed when The kidney was badly infected and contained a very
large stone or many small ones. The mortality in operations performed
for multiple stone was 3.5 per cent. Two of the deaths were due to
pneumonia, 1 to uremia, 1 to hemorrhage after nephrectomy and 1
was attributed to the anesthetic.

Gonococcal Infection of the Kidney. An interesting case of gonococcal
infection of the kidney lias been reported by R. R. Simmons.1 It was
that of a man who had had gonorrhea for four or five months and who
received a very hard blow on the abdomen which necessitated an
exploratory laparotomy. No signs of injury could be found within
the peritoneal cavity, but there was a mass in the region of the right
kidney. The patient was turned over and the kidney exposed through
a lumbar incision. The renal substance had undergone considerable
destruction as the result of hydronephrosis and through its thinned
cortex beneath the unbroken capsule a break in continuity could easily
be felt. Thus, it was seen that the attenuated renal tissue had been
fractured by the force applied to the abdominal wall. The kidney
pelvis was explored for stones, but none were found. Smears were
made from the pelvis and its contents, and a large number of intra-
cellular and extracellular Gram-negative diplococci were found. They
were cultured and a pure growth of gonococci obtained. Simmons
was unable to determine exactly how long the gonorrheal infection had
been present in the kidney, as the patient was unable to recall any
symptoms that would point to its onset. Inasmuch as no vesical symp-
toms had been experienced, it seems probable that the renal infection
was of hematogenous origin. This case led the author to make an inves-
tigation of gonorrheal infection of the kidney, as the result of which he
was able to find only 24 authentic cases recorded in the literature.
Including the 1 which he reports, only 15 were proved to be pure
gonorrhea. In others, a mixed infection was present. The organism
most frequently found in association with the gonococcus was the
colon bacillus. Sixteen of the cases were in men. The earliest
symptoms referable to the kidney occurred ten days after the onset
of acute urethritis and the latest case occurred nine years after infec-
tion. There was an associated bacteriemia in 3 cases. In 6 cases both
kidneys were affected.

Lavage of the Renal Pelvis. To show the comparative effects of the
various solutions used for pelvic lavage, O'Connor2 performed experi-
ments upon 30 dogs. In some cases the injections were given by
gravity^ in others the syringe was used. It was found that when a non-
irritating solution was injected, no physical changes in the epithelium
of the pelvis or ureter were brought about by slight overdistention
continued for thirty minutes. With regard to the penetrating action
of various drugs, it was found that boric acid, acriflavine, brilliant
green, gentian violet, aluminum acetate and silver nitrate had very

1 Journal of Urology, February, 1922.

2 Journal of the American Medical Association, October 1, 1921.

154 BONNEY: GENITO-URINARY DISEASES

little effect below the epithelial lining. The penetrating power of
mercurochrome was greater than that of the other substances used, as
it worked its way through the superficial layers and came into contact
with the tubular epithelium and the parenchyma tips of the pyramids.
The submucosa and muscularis of the ureter and renal pelvis retained
the dye from five to seven days without any reaction in the surround-
ing tissue being produced. Within twenty minutes after injection, the
dye had travelled directly up the lumen of the individual tubule as far
as the glomerulus, but there was no dye in the opposite kidney.

Flavine and brilliant green stain the superficial layer and the
ureteral and pelvic epithelium a uniform yellowish green, and gentian
violet also stains them faintly; but no evidence of any of these dyes was
found in the deeper structures or renal tubules and there was no round-
cell infiltration near the dye. Following the injection of aluminum ace-
tate solution, retained for thirty minutes, the epithelial lining was
found intact, although the regularity of the cell strata was affected.
Silver nitrate produced a marked superficial reaction, but no evidence
of penetration could be found below the epithelial lining. Six days
after its injection disintegration of the epithelial cells ceased and evi-
dences of regeneration were observed. In ten days the epithelial
lining was completely restored and the superficial layers of the cells
were intact.

The author suggests that the alternating use of mercurochrome, or
some equally penetrating dye, and silver nitrate may give better thera-
peutic results than will be obtained by the continual use of only one of
these substances.

Functional Renal Diagnosis. A symposium upon this subject was
recently held at a combined meeting of the Berlin Urological Society
and the Society of Internal Medicine,1 in which both the surgical and
medical aspects of the subject were discussed. Casper stated that
urologists should take into consideration not merely surgical diseases
of the kidney, but that they should also be familiar with the tests
applied in medical renal cases. The injection of coloring matter,
iodide of potassium, milk sugar and other substances, with dilution and
concentration tests; the estimation of urea in the blood; the excretion
of salt, and the determination of Ambard's index will enable one to get
an idea of the different separate activities of the kidney and to formulate
appropriate methods of treatment. While the internist has to deal
with disease in both kidneys, the surgeon's activities are usually con-
fined to only one kidney. The latter's problem therefore is to deter-
mine the functional capacity of each kidney separately and to form
an opinion if one is capable of carrying on the work of the organism
after the other has been removed. With reference to the latter subject,
frequent tests are advised, and in the author's practice the following
ones are made. After testing the urine obtained from each kidney
separately by means of the ureteral catheter, one of the color tests is

1 Zeitschrift fur Urologie, 1921, Heft 8.

DISEASES OF THE KIDNEYS AND URETER 155

performed; this is followed by a phloridzin test; and, finally, compari-
son is made between the blood nitrogen and the nitrogen in the urine
of each kidney. He also employs the concentration and dilution tests.

The former consists in determining the concentration of the urine
when the least possible amount of fluid is drunk. In healthy persons
it has been found that the specific gravity in such cases is 1.025 to 1.035,
hut in kidney insufficiency the specific gravity remains about constant,
the water being drawn from the kidneys and the individual losing weight.
In this test errors of calculation may arise from the amount of water
stored up in the tissues at the beginning of the test so that the con-
centration may not increase. In edema, therefore, the test is not
applicable. Such an error may perhaps be overcome by a preliminary
determination of the concentration at a time when the patient is taking
a moderate amount of fluid.

In the dilution test the patient drinks 1| liters of water or weak tea.
The rapidity of the dilution is determined by taking the specific gravity
of the urine voided. Extrarenal factors, such as cardiac weakness and
edema, also influence the result in this test. Richter, who took part in
the symposium, attributes considerable value to these tests when both
give a positive result.

( Jasper still thinks highly of the phloridzin test. That the excretion
of sugar takes place in the kidney is shown by an experiment that he
has recently performed : namely, the injection of the drug into the renal
arteries. For example, if it be injected into the right renal artery it
appears in the urine from the right kidney. This test he considers
superior to any of the color tests and also better than the potassium-
iodide test. When 0.01 of phloridzin is injected subcutaneously or
intramuscularly, the healthy kidney secretes glucose in fifteen to twenty
minutes after injection and ceases to secrete it in two or three hours.
So regularly have these phenomena taken place in thousands of cases
that the author states the absence of sugar secretion distinctly shows
the kidneys are not performing their function. It is in such surgical
conditions as pyonephroses, large hydronephrosis and tumors, in which
there is extensive destruction of renal tissue, that this test is the most
valuable. Acute diffuse glomerular nephritis does not prevent the
phloridzin reaction except in the very advanced stages in which atrophy
has taken place.

Attention is called to the possibility that occasionally an operable
case may be pronounced inoperable owing to the results of functional
tests, but it is certain that many more cases which are inoperable are
saved from an operation which would prove fatal. The mortality of
nephrectomy at present is stated to be from 2 to 4 per cent, and much
of the credit for its reduction is attributed to the employment of the
functional tests. Casper states that the average mortality before these
tests were made as a matter of routine was more than 26 per cent.
Doubtless other factors besides the functional tests have contributed to
its reduction, but the latter has certainly brought about a considerable
lowering in the rate.

156 BONNE Y: GENITO-VRINARY DISEASES

Tardo1 contributes an article on phenolsulphonephthalein, his object
being to compare the results obtained with those given by other methods,
particularly the secretion of urea and the ureosecretory constant.

The first thing- that impressed itself upon the author was the almost
mathematical correspondence between the urea output and the phthalein
secretion. In some cases, however, in which the urea debit was satis-
factory, the phthalein excretion was low. In order to investigate this
discrepancy the phthalein test was made in conjunction with the deter-
mination of Ambard's constant. In every case of this kind an azotemia
was found together with a high constant; so it seems that the phthalein
debit showed the true functional condition of the kidneys, whereas the
calculation of the urea alone was misleading.

In cases in which the urea function was markedly diminished, the
phthalein debit corresponded generally to the ureosecretory constant.
In cases in which the urea function was not diminished and the kidneys
were normal, the outcome of the three, namely, urine debit, phthalein
debit and Ambard's index, were in accord.

In a recent contribution, Aiello2 discusses the importance of the
residual nitrogen of the blood in renal functions. The term is applied
to nonproteid nitrogenous substances of light weight, of which there
are always small quantities circulating in the blood. Under normal
conditions its components are urea, which may be said to vary from
52 to 75 per cent; creatin, 6.15 per cent; uric acid, 3 per cent; amino-
acids, 8 per cent; ammonia, 0.4 per cent. The author believes that
for an exact determination of the renal function, an examination of
the blood for residual nitrogen gives a much more accurate result than
the examination for urea. The technic is described in detail, but as
the performance of the test comes solely within the domain of the
physiologic chemist it will not be discussed here.

Lawrence T. Price3 also speaks favorably of this test, and likewise
attributes great value to the creatin determination, a method which
was described in this review several years ago. He states that reten-
tion of more than 2.5 mg. per 100 cc of blood shows that recovery will
not take place.

Perirenal Inflation. A new diagnostic method which has aroused con-
siderable interest is that introduced last year by Carrelli and Sordelli,4
of Buenos Aires, and which consists in injecting oxygen or carbon
dioxide into the perirenal fat. The method has recently been demon-
strated in this country and in Europe by its author, and a number of
reports concerning it are to be found in the literature of the last few
months.5 From the information at present available, it would seem
that the essential points in the technic may be summarized as follows:
Accurate localization of the transverse process of the second lumbar

1 Journal d'Urologie. 2 H Policlinico, October 3, 1921.

3 Virginia Medical Monthly, 1921.

4 Rev. Anal. Medic. Argent., 1921, No. 200.

5 Rost* British Medical Journal, December 10, 1921; Hernaman Johnson: British
Medical journal, January 21, 1922; Delhern and Laguerrier: La Prcsse Medicale,
February 15, 1922; Delhern and Morel-Kahn: Paris Chirurgical, April, 1922;
Chevassu and Maingot: Journal d'Urologie, February, 1922.

DISEASES OF THE KIDNEYS AND URETER 157

vertebra; the use of a fine needle, which should be open while it is being
passed through the tissues; the proper direction of the needle after it
has struck the transverse process; determination of entrance of the
needle-point into the perirenal fat by manometer readings; and, finally,
slow injection of gas. Not more than 500 cm. should be injected.
As carbon dioxide is more readily absorbed than oxygen, it may be
considered tl e substance of choice. The method is to be employed in
those cases of renal disease in which ordinary roentgenographic exami-
nation proves unsatisfactory. It is stated that the kidney can be seen
much more plainly than when the ordinary roentgen-ray method is
used and that the suprarenal body can also be brought into view.

Hernaman Johnson describes a demonstration which he witnessed as
follows: The site of the second transverse process having been ascer-
tained, a f'ne platinum needle about 10 cm. long was pushed in vertically
until brought to a stop against the bone. Having called our attention
to the fact that the needle was actually against the process, Carrelli
proceeded to alter the direction of the thrust, carrying the point of the
needle slightly forward and a little outward, so that it slipped past the
obstruction. He pushed the needle in until he believed he had reached
the perinephric areolar tissue. He then waited a moment to see if any
blood came out through the needle. Had this occurred, it would have
meant that a vessel was punctured, and reinsertion would have been
necessary. Having satisfied himself as to this, he next connected the
needle with the manometer of the oxygen container. As soon as the
connection was made one saw the column of fluid in one of the bottles
move up with inspiration, down with expiration. Then the manometer
connection was closed and the stop-cock connecting the needle with
the oxygen chamber was opened. The injection was made very slowly.
The patient complained of an increasing ache in the loin and asked for
the injection to cease after it had reached about 500 cm. Carrelli 's
usual procedure is to turn the patient on his back and take plates
from above. In this demonstration, however, he used the fluoroscope
while the patient was lying face downward, and the kidney was plainty
seen standing out like a little island in a lake of air, according to John-
son's phraseology. The apparatus is simple, being similar to the one
used for producing artificial pneumothorax and pneumoperitoneum.

Chevassu and Maingot are not especially impressed with this method,
as they have found it technically difficult and have also had some acci-
dents, among which may be mentioned a mediastinal and cervical
emphysema which gave rise to alarming symptoms. The needle has
also been carried through into the peritoneal cavity, even by Carrelli
himself, and the authors state that insufflation of the psoas muscle is
not uncommon. In some cases pockets of gas seem to be formed around
the kidney, giving an irregular outline to the organ which might mislead
one into making an erroneous diagnosis. On the other hand, Delhern
and Morel-Kahn state they have employed the method in 50 cases
without having any accidents whatever.

It would seem that a similar method, though differing slightly in

158 BONNEY: GEN I TO-URINARY DISEASES

technic, has been employed by P. Rosenstein1 and other German
surgeons. In a recent contribution H. Boeminghaus2 states that he
has used it in 38 cases and that he considers it valuable. That it is
free from danger however, he is not willing to admit, for in 1 case a
patient developed signs of embolism after its employment.

Fistula Following Ureterotomy. At the April meeting of of the New
York Surgical Association, Lewisohn3 showed a woman, aged thirty-
two years, upon whom he had operated for ureteral stone five months
before. She had had typical attacks of colic for a year prior to her
admission to the hospital. They were very severe and occurred every
few weeks. Roentgen-ray examination showed a very small calculus at
the vesico-ureteral junction.

At operation, the left ureter was exposed 2\ inches above its entrance
into the bladder. Attempts to push the stone downward were unsuc-
cessful. The ureter was incised and a further attempt made to dis-
lodge the stone with instruments. These manipulations failing, it was
then decided to cut down upon the stone itself. Further liberation of
the ureter was effected and another incision made over the stone, which
was finally removed with the aid of a sharp spoon curette. Both
ureteral incisions were closed with catgut.

The incision at the uretero-vesical junction healed without delay.
The incision first made into the ureter, however, did not heal, with the
result that a complete urinary fistula was established. Cystoscopic
and ureteral catheterization showed what appeared to be a complete
obstruction on the left side about 2\ inches above the orifice. Even
very fine bougies could not pass the obstruction.

The patient was much annoyed by the profuse flow of urine
through the fistula, which made very frequent changings of dressings
necessary. Nephrectomy was advised, as spontaneous cure appeared
to be out of the question after so long an interval, and also in view of
the cystoscopic findings. However, to the surprise of all who followed
the case, the fistula closed spontaneously two and a half months after
the operation. No untoward symptoms followed closure and the
patient has been in perfect health during the last year. A recent
cystoscopy showed a well-functioning kidney, and also a slight stricture
at the site of the previous urinary fistula.

DISEASES OF THE BLADDER.

Malignant Tumors. At the present time the consensus of opinion
favors treatment of benign vesical growths by the high frequency spark
applied through the cystoscope in all cases in which the location and
size of the tumor make it possible to reach and destroy it by this
method. The original work of Beer, of New York, received notice
in this review a number of years ago and since that time the
experience of numerous urologists has been recorded. For the

1 Zeitschrift fur Urologie, 1921, Bd. 15, Heft, 11.

2 Zeitschrift fur urologische Chirurgie, 1922, Bd. 9, Heft"2.

3 Annals of Surgery, August, 1922.

DISEASES OF THE BLADDER 159

destruction of benign papillomas the method leaves nothing to be
desired. As experience has accumulated, it has been found that endo-
vesical fulguration Is not applicable to papillomatous growths which

present induration or circulatory changes around the base, even though
they appear to be benign. In such cases it is better to open the bladder
and treat the neoplasm more thoroughly at one time than can be done
through the scope.

The application of Beer's method to malignant vesical tumors has
also received some attention and the experience of Young and others
in this class of cases has been narrated in previous issues of Progress i \ i :
Medicine. During the year, two interesting papers upon the subject
have come to my attention. One is by Kolischer and Katz,1 of Chicago,
and the other by Corbus,2 of Chicago.

Kolischer and Katz have treated 27 cases of malignancy by diathermy
applied through a suprapubic vesical incision. Of this number, 25 were
free from recurrence at the time the report was made. Inasmuch as
only short periods had elapsed in many of their cases at the time their
paper was published, it does not seem safe to draw definite conclusions
concerning the prognosis. They state that one of their patients was
operated upon "more than three years ago."

Certain points in the technic employed are of interest. If the tumor is
a large, arboraceous one, a multi-spiked electrode is first applied to it and
a heavy shower of sparks is thrown over its surface, thereby producing
coagulation or carbonization before the deeper portion of the growth is
attacked. By this procedure bleeding is prevented during the later stages
of the operation and the danger of implantation of any detached tumor
fragments is prevented. If the tumor is pedunculated, its seared top is
grasped with forceps and pulled forward, after which the pedicle is severed
with a galvanocautery. The resulting stump and adjacent area are
then coagulated with a stamp-shaped electrode. If the tumor is den-
dritic, but without a well-defined pedicle, the initial sparking is done
with a single-spiked electrode. The sparks emitted from the latter
cover a smaller area than those from the multi-spiked instrument, but
penetrate more deeply. After the tumor has been thoroughly burned,
the stamp-shaped electrode is applied for the purpose of coagulating
its base. Burning is continued until a dry crust is formed and no oozing
of blood can be seen. As a rule, this crust is white, but if the tumor is
very vascular, it will be black in color. The electrodes are never
pushed into the tumor mass. Sessile infiltrating tumors are treated
solely with the stamp-electrode without any preliminary sparking.

The authors devote some space to a consideration of the extent to
which coagulation should be carried out. In their early experience
they considered it necessary to coagulate the entire tumor mass, but
as they became more experienced they found that better results were
obtained in the long run by not burning too deeply, leaving the unde-
stroyed portion to the influence of the roentgen rays, which are applied
in massive dosage forty-eight hours after the coagulation. With regard

1 Journal of the American Medical Association, May 27, 1922.

2 Surgery, Gynecological, and Obstetrics, November, 1921.

160 BONNEY: GEN ITO-URI NARY DISEASES

to this subject, it has been found that if a malignant growth which
involves the vesicorectal septum is completely coagulated, a cloaca
will remain after the incinerated mass of tissue has sloughed away.
Such a sequel will not only be very distressing to the patient, but will,
in all probability, lead to renal, or even general, septic infection.
Preoperative irradiation is not considered advisable. The authors also
advise against the use of radium in these cases.

Corbus1 publishes an interesting article on treatment of cancer of
the bladder by diathermy, not only describing his technic, but also
reporting some experiments which he carried out upon dogs with the
assistance of V. J. O'Connor.

With regard to the former, the following considerations are of import-
ance: First, the table is covered with several layers of thin paper over
which is placed a rubber sheet | inch thick, which must extend up to
the head-piece of the table to insure perfect insulation. Over this a
heavy woollen blanket is placed. The operator and his assistant should
stand on wooden platforms which are covered with paper and strips
of rubber £ inch thick. The indifferent electrode consists of a piece of
blocked tin about 5 or 6 inches square, and is placed under the patient
just above the buttocks. Between the electrode and the patient's skin
a gauze sponge wet with hypertonic salt solution is placed, for the
purpose of lessening the danger of superficial burning. This gauze
should be wet from time to time during the operation. The author
advises that the area of skin which has been in contact with the indiffer-
ent electrode should always be examined after the operation to deter-
mine whether any burning has taken place. If the operator uses a
head-light, he should take the precaution to have the current supplied
from a storage battery. Ether should not be used if it can be avoided,
because of the danger of combustion, or of short-circuiting of the current.
Rubber, instead of metal, retractors are employed, as the former are non-
conductive. The active electrode consists of a piece of rubber through
which there is a metal core. The conducting cord of the high fre-
quency machine screws into its proximal end, while the electrode fits
into the distal extremity. The kind of electrode used depends upon
the size of the growth and its situation. Corbus has found that a
Barnes' bag placed in the rectum is of considerable assistance in expos-
ing the area to be treated. Furthermore, it acts as a sheath to protect
the rectal wall. Another device employed for the protection of the
bladder wall is a glass speculum, which is placed over the neoplasm, and
through which the active electrode is passed. If the tumor is large,
the speculum is applied to one area after another, each being destroyed
in succession. The tumor is thoroughly coagulated. After the elec-
trode has been applied for a certain length of time, bubbles of gas and
steam are given off and cracking sparks jump from the sides of the
electrode to the adjacent tissue. This occurrence indicates that the
area receiving the application has been sufficiently burned. The supra-
pubic wound is kept open during convalescence, the author employing

1 Surgery, Gynecology and Obstetrics, November, 1921.

DISEASES OF THE BLADDER 161

the method devised by Richer, previously described in this Review, for
making his preliminary cystotomy in the two-stage operation of prosta-
tectomy. The suprapubic fistula not only places the bladder at rest,
but also makes it possible to observe the tumor mass by suprapubic
cystoscopy, and to permit the application of radium, if it be desired, as
a supplementary treatment.

The animal experiments are very interesting. They were performed
upon dogs deeply anesthetized with chloroform and were carried out
under the strictest aseptic precautions. The results of these experi-
ments show that the normal bladder wall subjected to diathermy is
followed by distinct and uniform tissue reaction. The important effect
is the slow coagulation of the underlying tissues, the effect upon the
deeper structures being the same as that upon the mucosa. This is
followed by an aseptic death of the submucosa and muscularis. Round-
cell infiltration is marked only for the first three days. Eventually,
the entire area is replaced by a dense proliferation of fibrous tissue, the
line of demarcation between the treated area and the surrounding nor-
mal tissue being definitely preserved. The ureteral wall may be burned
back almost to the entrance of the intramural portion. Three dogs so
treated and kept under observation from three to five months
showed no derangement of function either in ureteral activity or con-
tractility of the bladder. No obstruction to the ureteral outflow
occurred in five months. This burning back of the ureter is advised in
connection with the removal of neoplasms situated around the ureteral
orifice.

Radium in Cancer of the Bladder. From an experience with 24
advanced cases, G. G. Smith1 concludes that it is hopeless to attempt
to cure cancers which infiltrate large areas of the bladder wall, because
any dosage which might influence the tumor will cause necrosis of the
bladder. In superficial growths benefit has been obtained, in the
sense that the neoplasm has become smaller under the application of
screened radium emanation. The optimum dosage is 400 millicurie
hours, with screening through 0.5 mm. of silver, applied not oftener
than once in six weeks. The best mode of application is by the implan-
tation of pure emanation tubes in the tumor, allowing one tube to each
cubic centimeter of the growth.

Cystography. Roentgenograph^ and fluoroscopic examination of the
bladder after it has been injected with materials more or less impervious
to roentgen rays, is a diagnostic method concerning which Neil Moore,2
of St. Louis, has recently recorded his experience. In Progressive
Medicine some years ago attention was called to the value of cystog-
raphy in examining children. At that time the small caliber cystoscope
had not come into general use.

Moore has found this method of the utmost value in ascertaining the
size, shape and position of the bladder; the number, size, shape and
position of the vesical diverticula; and in the diagnosis of hydrometer
with disturbance of the mechanism of ureteral closure. Furthermore,

1 Surgery, Gynecology and Obstetrics, November, 1921.

2 Journal of Urology, August 1, 1922.

162 BONNEY : GEN I TO-URINARY DISEASES

he believes it to be of great value in the diagnosis of calculi in the pos-
terior urethra and prostate, some vesical calculi, and those tumors of the
bladder of such dimensions that a correct idea of their size, shape and
position cannot be ascertained by means of cystoscopy. In those old
men affected with hypertrophy of the prostate, whose general condition
is such that cystoscopic examination is likely to upset them, he expresses
the opinion that much useful information can be obtained by cystography.
Materials in general use for injecting the bladder are solutions of
sodium bromide or sodium iodide, 5 to 20 per cent, and thorium nitrate,
from 5 to 15 per cent; emulsions of organic silver salts; and gases, such
as air and oxygen. Moore favors 10 per cent sodium bromide solution,
although he states that it does not give as clear a shadow as silver iodide
emulsion. He has found that the silver emulsions in general precipitate
so rapidly that the precipitate may cast a shadow. The technic of
injection and exposure is described in detail.

DISEASES OF THE PROSTATE.

Carcinoma. The increased interest aroused in the prevention and
control of malignant disease, as the result of efforts made by societies
founded for that purpose, is manifest in present-day surgical and
medical literature. Not only is the importance of early diagnosis and
the therapeutic possibilities depending thereon generally better under-
stood than they were a decade ago, but new methods, surgical as well
as those in which physical agents are utilized, are being tried by a con-
stantly increasing number of members of the medical profession. Con-
cerning the physical agents, it may be stated that the interest centers
in radium. Its application in malignant disease of the prostate has
furnished material for several reports during the last year. Among the
number may be mentioned first those of H. G. Bugbee1 and B. S. Bar-
ringer,2 of New York. Other important contributions to the subject
have been made by Young and Deeming; Geraghty, Chute, G. G.
Smith and Bumpus. All will receive notice in the pages that follow.

The enthusiasm which marks the reports of certain writers on radium
therapy in malignant disease of other organs and systems of the body is
absent from those here referred to. Hopefulness, together with willing-
ness to judge from actual results rather than from preconceived ideas,
shows a healthful mental attitude.

Bugbee states that although his early experiences were not encourag-
ing, he has obtained better results during the last few months by use
of radium than he has ever been able to obtain by other means.
Early in his experience applications were made through the rectum
and urethra, and while the carcinomatous growth was frequently soft-
ened and reduced in size, the local irritation was also often increased
and the patient suffered considerably from toxemia. More benefit has
been derived from exposure of the prostate through a suprapubic cys-
totomy and introduction of the radium needles directly into its sub-

1 Journal of Urology, December, 1921.

2 Surgery, Gynecology and Obstetrics, February, 1922.

DISEASES OF THE PROSTATE 163

stance; and also in certain cases from the passage of radium needles
into the prostate through the perineum. A series of 1 7 eases is reported,
5 of which were treated according to the last named method, supple-
mented by direct application to the rectal surface of the prostate. In
1 eases hit ranrethral applications were also made. At the time the
report was published, no hard tissue could be palpated through the
rectum in .'! of these patients. In one a single firm nodule, much
reduced in size, was still present; and in the other a rapid softening of
the extensive infiltration was taking place. In 4 cases application was
made through a suprapubic opening and needles were also passed
through the perineum into the gland. Rapid shrinkage of the tumor
took place in all these cases. In 1 patient, who received surface appli-
cations of radium in conjunction with the above-described treatment,
healing of the suprapubic opening took place. In 2 cases improvement
followed the punch operation and the application of radium. Attention
is called to the necessity of getting patients into the best possible
physical condition before radium is applied. Elimination must be
active and the blood index good if cancerous tissue is to be destroyed and
eliminated without producing profound toxemia. The author states
that the toxemia is now not nearly so severe as that which he observed
in his earlier cases.

In this series 4 patients were in such bad condition that nothing but
suprapubic drainage was attempted. In 1 other case prostatectomy,
with resection of the bladder wall, followed by radium, was performed,
and in still another, the treatment was confined to the insertion of
radium needles through tl\e perineum.

Barringer's report is based upon the study of 145 cases in the Memorial
Hospital, New York. He states that the technic first used, and which
was described in Progressive Medicine a number of years ago, has
given him better results than that obtained by any other method of
application. It consists in passing radium needles into the prostate
through the perineum, novocain anesthesia being employed to render
the procedure painless. The needles are from 10 to 15 cm. long and
of No. 18 gauge. From 50 to 100 millicuries of radium are placed in
the terminal 3 cm. of the needle. It has been found that a carcinoma-
tous mass 2 cm. in diameter may be first treated from 300 to 400 milli-
curie hours. In two or three months the second application is made,
the dosage, however, being smaller. In certain cases from 25 to 50
millicuries have been applied every week, but the author has not found
that the results obtained are superior to those following the larger
dosage at longer intervals.

If the seminal vesicles can be reached, they are irradiated in the same
manner. If the prostate, however, is so large that they are not easily
accessible, an application may be made to them through the rectum.
A finger is inserted into the rectum and a small cannula is passed along-
side it until the vesicle is reached, whereupon the needle is passed
through the cannula and pushed onward into the vesicle. It is stated
that no infections have followed this method of application.

The use of radium in the prostatic urethra has been limited to cases

164 BONNEY: GEN I TO-URINARY DISEASES

in which carcinoma has broken through its wall. Tubes of screened
radium 2 cm. long are attached to a linen thread and inserted into the
bladder through the sheath of a urethroscope. Then the urethroscope
is removed and the tubes pulled out into the prostatic urethra by the
attached thread. When the treatment is finished, the tubes are pulled
out of the urethra in the same manner. The maximum dose is 200
niillicurie hours.

If residual urine gives rise to serious symptoms, bare tubes of radium
are applied to the vesical neck. A tube containing 6 millicuries of
radium is placed in the end of a flexible needle which is passed through
a McCarthy urethroscope or an operating cystoscope. By means of
a plunger, the bare tube is pushed out of the needle into the prostate
and left there. Its action is local and caustic. If the urinary symp-
toms are not relieved and the quantity of residual urine reduced by this
treatment, a punch operation, suprapubic drainage, or partial supra-
pubic prostatectomy is performed.

Barringer's statistics show the hopelessness of many cases of car-
cinoma of the prostate. Although 1 out of 7 of his patients came under
observation within the first two months after the appearance of symp-
toms, 1 out of 3 within six months, and 2 out 3 within the first year, in
each and every case the disease had extended beyond the gland. In
only 2 per cent of cases forming this series was the disease apparently
confined to the prostate itself. In view of these circumstances, routine
examination of the prostate in all men more than fifty years of age,
irrespective of the existence of symptoms, is recommended as the only
rational method by which an early diagnosis of prostatic carcinoma
can be made.

In conclusion the author states that he considers radium treatment
to be superior to operative removal of the carcinomatous prostate.

Young and Deeming1 have also published articles upon the radium
treatment of prostatic carcinoma, the former describing the technic
and the latter recording the results obtained in a series of 100 cases.
Young has devised an applicator which shortens the period of applica-
tion, so that 200 milligram hours can be given in an hour's time. This
applicator carries two tubes of radium, each containing 100 mg. in its
beak. They are placed end to end and are thoroughly screened with
2 cm. of platinum and a thin layer of gutta percha. The author states
that with this exception the only modification that has been made
during the last four years is to avoid making an application twice in
the same place. The successive treatments should be given in differ-
ent areas as far apart as possible and alternating between the rectum,
urethra and bladder. With regard to rectal applications, it has been
found possible, by means of the technic in which the radium is placed
in position with the finger in the rectum and held there by the eysto-
scopic clamp, to give as many as twenty treatments of one hour each.
No burning has been produced by this method. Needling of the peri-
neum has been used in conjunction with the other methods. No local

1 Surgery, Gynecology and Obstetrics, January, 1922.

DISEASES OF THE I' HOST ATE L65

anesthetic is required in the rectum, but an injection of I per cenl
procain is made before the applicator is passed into the urethra and

bladder. A hypodermic injection of g gr. of morphine half an hour before
treatment has been found serviceable in patients who complain of pain.

Deeming's paper slums the results obtained at the Brady Institute
in 100 eases treated with radium. All of the patients were suffering
from advanced and extensive lesions which contraindicated surgical
intervention. Relief of symptoms was obtained in 75 per cvwt of the
cases, 3 patients remained free from symptoms and increased growth
of the neoplasm for more than four years, and there were a number of
others who, upon rectal examination, presented a condition of the
prostate which did not resemble cancer. There were '2'.] patients who
did not react to treatment, but a study of their eases shows that tin-
average amount of radium given was only 625 milligram hours. The
average for those receiving at least some improvement wTas 1415 milli-
gram hours. Thus, it is only fair to assume that failure to obtain
results in the above-mentioned group of cases, was due to the fact that
insufficient dosage was employed. The opinion is expressed that from
4000 to 5000 milligram hours in a period of six to eight weeks should
be given, and in addition needle treatments of 500 to 2000 milligram
hours should also be made through the perineum.

H. C. Bumpus, Jr.,1 of the Mayo Clinic, calls attention to the fact
that the relative degree of malignancy, as shown by the character and
arrangement of the epithelial cells, affords an index to the prognosis.
Thus, if the proliferating cells are partly differentiated, fairly regular
in size and shape, and retain the characteristic long tufted ends, the
prognosis with regard to the duration of life is better than it is in those
cases in which the epithelium shows little or no tendency to simulate
the normal type and is irregularly dispersed through the fibrous tissue.

A very important point is made by Bumpus with regard to the surgi-
cal treatment of carcinoma of the prostate. Eleven per cent of the
patients in a certain series who were treated surgically are living at the
end of six years, and 9 per cent are alive at the expiration of nine years.
In contradistinction to those who were operated upon, all in another
group who were not operated upon had succumbed at the end of six
years. As the author remarks, this shows that it is possible occa-
sionally to remove all the malignant cells by conservative surgery.
Undoubtedly, many of those who were not operated upon were in such
a condition as to render surgery useless. Although it might seem only
fair to assume that as much could have been done surgically for some
of them had they come for treatment earlier as was done for those in
the former series, certain figures submitted by Bumpus show that
there was little difference in the final results obtained in the cases con-
stituting the two groups. In the former, in which operation was done
for suspected malignancy, 34 per cent of those who died succumbed
the first year, and in the latter, in which a positive diagnosis of malig-
nancy could be made, 35 per cent succumbed the first year. The

1 Surgery, Gynecology and Obstetrics, August, 1922.

166 BONNEY: GEN I TO-URINARY DISEASES

average length of life of patients in the early cases was about twenty-
six months, those in the later eases twenty-seven months. In both
groups only 9 per cent of those who died had lived more than three
years. Thus it would seem that the degree of malignancy is the deter-
mining factor in the prognosis. Both the perineal and suprapubic
operations were performed. Slightly better results were obtained in
the suprapubic cases.

In a series of 200 prostatectomies performed by Arthur L. Chute,1 of
Boston, it was found that the enlargement was malignant in 17.5 per
cent of the number. In reporting these cases, Chute discusses the
advisability of surgical intervention, and expresses the opinion that in
all instances where the growth is producing obstruction to urination,
an attempt should be made to remove it unless the patient's general
condition is too precarious to permit an operation. In some cases he
has found that the pain in the sacral region or thighs has been tempo-
rarily relieved by removal of the growth. In such cases, of course, the
indications for operation are less clear than when there is urinary
obstruction, and if there is any reason to believe that the pain is caused
by metastatic involvement of the spine, no operation should be under-
taken. The patients upon whom the author has operated were appar-
ently suffering because of lateral extension of the disease, which produced
pressure upon nerves a considerable distance beyond their exit from
the spine.

Three operative methods have been found useful by the author.
Removal by suprapubic enucleation is considered applicable only in
those cases in which the growth is intracapsular. In the majority of
cases in which the author employed it, the type of disease was not
recognized until the time of operation. In cases in which preliminary
suprapubic drainage has been made and the prostate is so dense and
firmly attached that it cannot be enucleated from above, combined
suprapubic and perineal removal is advised. This was satisfactorily
employed six times. All malignant tissue possible is cut away or
punched out through a median perineal incision under guidance of the
forefinger introduced through the suprapubic wound. In the majority
of instances the best procedure is one resembling Young's perineal
operation for removal of the adenomatous prostate. Chute employs
the classical position, incision and dissection of the perineum until the
prostate is reached; then he makes a transverse incision into the pros-
tatic tissue which permits the turning back of a flap, thereby aiding
in the protection of the rectum from injury. Removal of the diseased
tissue is accomplished by the finger, a dull periosteal elevator and
rongeur forceps. Special attention is given to the removal of the dense
tissue that surrounds the vesical outlet. For this purpose curved scis-
sors have often been found useful. Drainage is established by means
of a catheter in the urethra and perineal tubes in the wound. Radium
needles are now being inserted into any particles of suspicious tissue
that cannot be taken away. Ordinarily they are left in place from

1 Boston Medical and Surgical Journal, October 27, 1921.

DISEASES OF THE PROSTATE 107

twenty-four to forty-eight hours. The dose of radium has usually been
25 mg. This combined procedure was carried out in 26 cases, in 7 of
which spinal analgesia was used.

The author states that convalescence in cases of this kind is not
different from the convalescence following ordinary prostatectomy for
benign disease. That the ultimate results would be very dishearten-
ing if they applied to anything but a condition that is inevitably fatal,
is freely admitted by the author. He feels, however, that the relief
given the patients, together with a certain prolongation of life, fully
warrants the use of the methods which he describes. The hope is
expressed that the use of radium as an adjunct to surgical treatment
will give better results than have been obtained in the past.

Geraghty1 devotes considerable space to a study of this subject,
based upon the cases from Johns Hopkins Hospital, and. concludes
that in 95 per cent of all cases it is impossible to accomplish total
removal of the growth. Thus, complete removal was possible only in
21 out of 400 cases. In 14, Young's radical operation for carcinoma
was done, resulting in the cure of 50 per cent, while in 7 total prosta-
tectomy was performed, which resulted in a cure of the entire number.

During the last seven years radium has been used in the treatment
of malignant disease of the prostate, either alone or supplementary to
surgical treatment. During the earlier part of that period the technic
consisted in applying 100 mg. for one hour and repeating the applica-
tion every second or third day. The application was made through
the urethra and rectum. For the last year and a half 12.5 to 20 mg.
have been inserted into the prostate by means of needles passed through
the perineum and left in place from fifteen to thirty hours. As the
result of this treatment, in some cases at least, the prostate became
smaller and somewhat softer, but the symptoms of obstruction were
not much influenced, home patients so treated had to have a prosta-
tectomy done to relieve them of urinary symptoms. The author
remarks that in every case operated upon after the employment of
radium, distinct cancer tissue, apparently unchanged, could be found
in the removed gland. As a rule, the patients in this series did not come
under observation until the disease had involved the seminal vesicles
or the posterior bladder wall, a circumstance which accounts for the
small number of radical operations attempted.

Thomas and Pfahler2 recommend preoperative treatment with the
roentgen rays extending over a period of about two weeks. The area
treated includes the entire pelvic region, the object being to destroy
any outlying carcinomatous foci in the lymphatics and to temporarily
limit the extension of the disease. The insertion of radium needles
into the prostate through a suprapubic opening is also recommended,
each needle containing 10 mg. of radium. In some cases the prostate
has been exposed through the perineum, as much removed as possible
and radium then applied, this method thus conforming in principle
with that advised by Chute. At least two full doses of roentgen ray

1 Journal of Urology, January, 1922.

2 Archives of Surgery, April, 1922.

L68 BONNEY: GEN IT0-UR1 NARY DISEASES

are given after operation, the first about two weeks after the radium
application and the second three or four weeks later.

Hypertrophy of the Prostate. In an article entitled "Some Disputed
Points Regarding Prostatectomy," Chute1 discusses, among other
things, overdistention of the bladder, and also mentions 10 men who
died without being operated upon as the result of this condition and
the back pressure it exerted upon the kidneys. He states that he could
not, by any means, get them into proper condition for operation. It
was evident that some of them were critically ill upon admission;
others, however, seemed to be in fair condition, although the latter
group as well as the former, failed to improve under the measures insti-
tuted for their relief. In no case was immediate removal of the pros-
tate attempted, suprapubic drainage under local anesthesia being the
only operative procedure employed. It is evident that the author's
experience in this respect coincides with that of many others who have
had patients die while waiting to do the second step of the two-stage
operation. Chute prefers suprapubic cystotomy to catheter drainage
in this class of cases, believing that the increased shock of the supra-
pubic incision is more than offset by the better drainage obtained.

The phthalein output as an indication of operability is also discussed,
and the author expresses the opinion that as an index of renal activity
at the moment the test is made it is very dependable. However, as
it cannot give any information concerning of the potential power of
the kidneys, he feels that it cannot be of any help if performed only
once. When a kidney has been embarrassed by the back pressure of
a distended bladder, as in this class of cases, it will eliminate only a
trace of phthalein. After the pressure has been removed by drainage,
its function will improve and a fair output can be obtained after a few
weeks.

At this year's meeting of the American Association of Genito-Uri-
nary Surgeons, a new method of jwrforming perineal prostatectomy , for
the purpose of securing better functional results, was described by
Geraghty,2 of the Johns Hopkins Hospital. The author admits that
perfect urinary control following the usual perineal prostatectomy is
to be expected only in cases in which the prostate is small or only
moderately enlarged. In cases in which the gland was greatly enlarged,
he has found that partial incontinence of a few months' duration, or
occasionally permanent incontinence, follows the usual perineal opera-
tion.

The author's method is different from Young's in that he does
not expose the membranous urethra at any time, and consequently
does not injure its musculature nor disturb its nerve supply. It is
well known that incontinence rarely follows suprapubic prostatectomy,
a circumstance which the author states prompted him to investigate
the occurrence of the temporary incontinence not uncommon after the
perineal operation. In the latter, as usually performed, the external
sphincter is either dislocated or divided before the membranous urethra

1 Journal of Urology, June, 1922. 2 Ibid., May, 1922.

DISEASES OF THE PROSTATE 169

i> opened, and it is to this circumstance that the faulty functional
results are attributed. If the membranous urethra is opened without
stripping off the surrounding musculature, the fillers of the external
sphincter must be divided; if, on the other hand, the muscle which
encircles it is dissected forward or backward, considerable injury to
this muscle may result. The author's technic was designed for the
purpose of obviating this defect. The operation is described as follows:

The patient is placed in the usual exaggerated perineal lithotomy
position. A specially constructed prostatic tractor is passed from the
meatus into the bladder, the blades of the tractor opened and the
handle carried toward the patient's abdomen. This tractor, devised
by Henry Freiberg, differs from the Young seminal vesical tractor
in possessing a curve and shape which facilitates its introduction into
the bladder. It, furthermore, upon the opening of its blades, so engages
the prostate that its flat surface rather than the sharp edge is in con-
tact with the gland. This position of the tractor, using the symphysis
as a fulcrum, forces the prostate forward toward the perineum. In
the next step of the operation a semicircular perineal incision is made,
its center being about an inch anterior to the anal margin. The ischio-
rectal fossa1 are now opened with the finger and a bifid retractor intro-
duced, each blade of the retractor occupying a fairly deep position in
the fossa. When retraction is made, the central tendon is rendered
tense and prominent. This structure is then divided close to the
bulb, its division exposing the rectum. The rectum is now seen cover-
ing a varying amount of the posterior surface of the prostate and the
rectourethralis is seen holding the under surface of the bulb to the
rectum at a point close to the apex of the prostate. To facilitate the
stripping back of the rectum, a finger is introduced anterior and lateral
to the apex, the free margin of the rectum being readily picked up at
this point. The rectum is now easily and safely freed from the pros-
tate by finger dissection. By blunt dissection the fibers of the levator
ani are now separated in the midline in the region of the apex of the
prostate. The anterior fibers are now pushed laterally, while those
covering the body of the gland are pushed backward. The smooth,
glistening visceral layer of Denonvilliers' fascia is now exposed. It is
evident from the foregoing description that the membranous urethra
is not exposed and that its musculature is left undisturbed.

A curved incision is now made through the posterior layer of the
prostate, the point of the curve being at the apex of the gland and the
legs extending downward in a divergent manner. The form of this
incision preserves a flap containing the ejaculatory ducts, and, further-
more, gives a maximum exposure of the hypertrophied lobes beneath.
The line of cleavage between the capsule and the adenomatous masses
is effected by the blunt dissector and the subsequent dissection is
carried out by the finger as is done in the suprapubic enucleation.
The finger is carefully and gradually insinuated between the two layers,
the anterior or apical portion of the lobes being delivered first. This
facilitates the subsequent removal of the deeper portions of the gland,
especially the part which lies within the bladder. After the delivery

170 BONNEY: GEN I TO-URINARY DISEASES

of the apical portion of the lateral lobes, these portions are grasped
with forceps, by means of which traction is readily made. The sub-
urethral and intravesical lobes are then carefully freed from their
posterior attachment and from the grasp of the internal sphincter.
If, following the removal of the adenomatous mass, which is usually
possible in one piece, unusual bleeding takes place, the edge of the
mucous membrane is grasped with forceps and any bleeding vessels
ligated. A large single tube is now introduced into the bladder through
the opening in the prostatic capsule and long strips of gauze are packed
tightly around it up to a point well within the vesical orifice. The
prostatic cavity is next snugly packed, the gauze being guided into its
proper position by the finger.

It is well recognized by prostatectomists that the most serious
hemorrhage following prostatectomy arises from large vessels which
lie in the overhanging flap of the bladder wall from which the prostate
has been separated. If care is not exercised in packing from the peri-
neal side, this lip of bladder wall may be everted into the bladder
cavity, and no hemostasis will be effected at this point by pressure
of the pack, h'uch an accident may be avoided by grasping the edge
of the overhanging lip of the bladder wall with a mucosal clip, thus
fixing it until the gauze pack has been inserted between the tube and
vesical orifice. The observance of this technic will prevent eversion
of the torn edge of the bladder and possible serious intravesical
hemorrhage.

The tube is now sutured into the skin edge with heavy silk and the
remaining portion of the skin incision approximated with subcuticular
chromic catgut sutures.

Young1 has recently described a modification of his perineal opera-
tion which permits enucleation of the entire adenomatous mass in
one piece without injuring any important anatomic structures. After
the prostate has been exposed through the usual superficial incision
and the prostatic tractor has been introduced, an oblique incision is
made along the left side of the tractor where it enters the prostatic
urethra and is continued thence backward and slightly outward nearly
to the posterior limit of the prostate. The whole prostatic urethra is
thus widely opened, and the author states that the verumontanum can
be plainly seen along the floor of the urethra to the right. An incision
is then made along the mucous membrane of the urethra, covering the
inner surface of the right lateral lobe, and enucleation of the lateral
lobe is performed by means of the blunt dissector and the index finger.
The mucous membrane covering the middle lobe is then divided trans-
versely, the ejaculatory ducts and verumontanum being pushed back-
ward and guarded by the index finger, which is inserted along the floor
of the urethra until it reaches the middle lobe. An incision is next
made with the scalpel or finger-nail through the mucous membrane
covering the median portion of the prostate, after which the finger is
pushed backward beneath the middle lobe, thus freeing it from the

1 Journal of the American Medical Association, April 1, 1922.

DISEASES OF THE PENIS AND URETHRA 171

proximity of the ejaculatory ducts posteriorly. Enucleation of the
lateral and median lobes is then completed, first on one side and then
on the other, until the entire adenomatous prostate is drawn forward
and gradually separated from its attachment to the vesical and urethral
mucous membrane. If there is a subtrigonal lobule, the tractor is
removed and the index finger of the left hand is inserted through the
sphincter into the bladder. The deep portion of the middle lobe is
then removed upon this finger, a curette being used, if necessary, to
free its deep portions from the surrounding structures.

Of late sacral anesthesia has received considerable attention by a
number of prostatectomists, among whom may be mentioned A. J.
Crowell,1 L. A. Chute2 and G. G. Smith.3 Crowell describes his technic
as follows: A spinal puncture needle is inserted into the sacral canal
through the triangular space formed by the sacral cornua at the sacro-
coccygeal articulation. It is then directed upward parallel with the
sacral canal for 3 or 4 mm. and 30 cc of a 2 per cent solution of novo-
cain is injected slowly in order that it may thoroughly infiltrate the
tissues. Malformations of the spinal canal should be kept in mind
and a moment allowed to elapse after the obturator is removed to see
if the spinal fluid escapes. If so, the puncture should be made elsewhere.
Twenty minutes should elapse after the solution is injected before the
operation is begun. Blocking off the sacral plexus by this technic
anesthetizes the entire external field of operation so that all manipula-
tions are painless unless the traction necessarily made in many cases
on the pelvic peritoneum causes some pain, in which case nitrous oxide
may be required while enucleation of the gland is being performed.
Crowell states that postoperative pain is greatly reduced by this method
of analgesia.

Smith has employed sacral anesthesia in 10 cases and states that he
is enthusiastic about it. In 8 of his cases the perineal operation was
done, in 2 the suprapubic. In 1 of the latter the operation was com-
pleted without causing the patient any pain. The other case was that
of a very nervous man, who had to have a little ether before the opera-
tion was over. Smith states that he was of a very nervous tempera-
ment, and expresses the opinion that at least a "psychic" ether would
have been required in conjunction with any form of local anesthesia.

DISEASES OF THE PENIS AND URETHRA.

Epithelioma of the Penis. Eighteen cases of this form of malignant
disease have been reported by Shreiner and Kress.- In 3 radical
operation was performed, although preliminary roentgen-ray treat-
ment was employed. No metastases wTere found in these 3 cases. The
operation consisted of amputation of the penis, together with removal
of the testicles, scrotum and all lymph-bearing tissue in both groins.
The patients were alive and well four, three and two years later respec-
tively. Roentgen ray combined with radium was used in 2 cases, in 1 of

1 Journal of Urology, July, 1922. 2 Ibid. 3 Ibid.

4 Journal of Radiology, October, 1921.

172 BONNEY: GEN I TO-URINARY DISEASES

which the result was unsuccessful. In the other case the patient was ex-
posed to the unfiltered roentgen rays three times in six weeks, two ery-
thema doses being given on each occasion. The large nodes in the groin
were treated with radium, the filtration being through 0.5 mm. of silver,
1 mm. of lead, 1 mm. of aluminum and 1 cm. of rubber. A total appli-
cation of 9700 millicurie hours was made to each groin. The lesions
healed. Roentgen ray with conservative operation, consisting of
amputation and removal of lymph nodes, was used in 2 cases. One
patient was alive and well two and one-half years later, but the other
died from recurrence a year later. Six patients were treated with
the roentgen ray alone, the results being good in all these cases. One
patient was alive and well six years after treatment.

With regard to the duration of the disease, it is stated that signs had
been present from six months to two years before the patients came
under observation. In 6 cases there were definite metastases to other
regions of the body. In 12 there were palpable lymph nodes in the
groin, although in 5 of this number microscopic examination of the
nodes removed at operation failed to reveal any signs of malignancy.
In all cases in which definite metastases were shown in the lymph-
bearing tissues the treatment proved ineffective or at best only palliative.

The authors conclude that cancer of the penis can be healed with
unfiltered roentgen rays, and that improvement in the technic, as
well as earlier diagnosis and earlier treatment, may result in a greater
number of cures than have heretofore been obtained. In those cases
in which metastasis has already occurred in the lymph nodes, the im-
plantation of small doses of radium emanations, supplanted by radium
packs, has proved to be beneficial.

An important report on carcinoma of the penis, having special refer-
ence to -prognosis, comes from Garre's1 clinic, in Bonn, the report being
made by W. Peters, an assistant surgeon in the clinic. It is based
upon 25 cases and covers a period of thirteen years. Only those patients
who remained free from recurrence for more than five years are spoken
of as cured. Previous statistics show that this localization of carcinoma
occurs in advanced life and that one-third of all cases begin during the
sixth decade. As to the age incidence in this series, there were 9 cases
in men between fifty and sixty years; 5 in those between sixty and
seventy; 6 in those above seventy, and 5 in those under fifty. Examina-
tion of these figures shows that they do not differ essentially from those
previously reported by various surgeons. Very few of the number
were private patients, and, in discussing the etiology, the reporter
remarks that uncleanly habits may have had some influence in the
causation of the disease. Many of the patients were affected with
phimosis. In 12 cases the lesion first affected the glans; in 9, the pre-
puce; in 3, the coronary sulcus; in l,the undersurface of the penis close
to the scrotum. Various periods of time had elapsed since the appear-
ance of the lesions and the admission of the patients to the hospital.
Thus 9 applied for treatment within less than six months from the

1 Zeitschrift fiir Urologie, Band 15, Heft 10.

DISEASES OF THE I'ENIS AND URETHRA 173

time they noticed the trouble; 9 went from six months to one year, and
5 allowed more than one year to go by before seeking relief. In the
last group there were 2 who waited more than two years.

In discussing prognosis, the opinion is expressed that the duration
of the disease cannot he used as a criterion of the outcome of the ease.
Thus, the 2 patients just mentioned, who waited more than two years
before applying for treatment, are alive and well ten and thirteen
years respectively after operation. In contrast to these, one patient,
who was operated upon three months after the first appearance of the
lesion, died two years later as the result of extensive metastases. In
all cases in which metastasis to the lymph nodes was demonstrable,
the lesions on the penis had not been present for more than six months.
It is interesting to note that in 17 cases in which the inguinal glands
were removed, carcinoma was demonstrable microscopically in only 2.
As the author remarks, some error in the reports very likely occurred
because the pathologists could not possibly make serial sections of each
and every gland. This finding is at variance with the microscopic
findings in other series of cases.

The results obtained in this series may be tabulated as follows:
Three patients died after the operation — 1 from pyelonephritis, 1 from
pulmonary edema and 1 from pulmonary embolism. Three others
died from metastases— 1 a year after operation, 1 two years afterward
and 1 eight years afterward. The last-mentioned was eighty-seven
years of age. Death was reported to be due to carcinoma of the bladder
and pelvis. Five others died of intercurrent affections at periods
varying from four to nine years after operation. There were 14 remain-
ing free from recurrence and metastasis at the time the report was
published. Ten of the number have passed the five-year limit and 6
have remained entirely free from nine to thirteen years.

Of great interest is the question whether extensive removal of all the
regional lymph nodes exerts any special influence upon the end-results.
In 8 cases of the series no inguinal dissection wras made because the
patients would not consent to it. One of the number died within a
year from metastasis. Another succumbed to the same condition in a
little more than a year. Four showed no signs of metastasis at the time
the report was published. The other 2 died of intercurrent affections
eight or nine years respectively after operation. Despite the excellent
results in half of these 8 cases, the author is unwilling to admit that
the removal of the inguinal nodes, even wrhen they are palpably enlarged,
is a superfluous procedure. In all cases in which the lesion on the
penis increased rapidly in size, and in which there is evidence of exten-
sion to the corpora cavernosa and early enlargement of any regional
nodes, he feels that the most extensive operation possible is in order.
In this connection the procedure of Cunningham, of Boston, is mentioned.
The importance of clearing out the inguinal region even when the
nodes are not palpably enlarged is shown by one of the cases— that of
a man who would not consent to an inguinal dissection. He came
back six months after operation free from local recurrence, but pre-
senting a large mass in one groin. It was removed and found to be

174

BONNEY: GEN I TO-URINARY DISEASES

carcinomatous. The patient was seen six months later, at which
time he had inoperable metastases in the pelvis.

The management of inoperable cases is also discussed and palliative
operation, consisting of amputation of the penis and removal of access-
ible lymph nodes, particularly those in the groin, is recommended.
The roentgen rays have not been used in this class of cases.. The
author stated that it is a dictum in Garre's clinic that that which is
operable is operated upon.

Fig. 2. — Penis incased in condom. Lines of incision. Abdominal and inguinal
fat mass partially freed. (Cunningham.)

Cunningham,1 at a recent meeting of the New England branch of
the American Urological Association, showed 2 patients upon whom he
had operated according to his radical method. Both of these patients
had been subject to chronic irritation, 1 having suffered from phimosis
since birth, the other having been subject to warts beneath the prepuce
and having had repeated cauterizations performed for their removal.

1 Transactions of the New England Branch of the American Urologyical Associa-
tion, Winter 1921. Journal of Urology, June 6, 1922.

DISEASES OF THE PENIS AND URETHRA

175

In showing these patients, Cunningham took occasion to describe the
technic of his operation, which is as follows:

1. A condom is placed over the penis to prevent implantation of
cancer cells during the operation.

2. A sweeping U-shaped incision is made, beginning slightly above
and to the inner side of the anterior-superior spine on one side, extend-
ing downward in the fold of the groin to the root of the penis and
upward on the other side. This incision passes just through the skin
(Fig. 2) and outlines an apron which is dissected upward.

Fig. 3. — The scrotum partially bisected. The dorsal veins tied. The crura
separated from the pubic rami and their stumps tied. The membranous urethra
separated from the bulb. The abdominal fat mass above. (Cunningham.)

3. An incision, passing through the skin, is made downward over
Scarpa's triangle from the center of Poupart's ligament. The skin is
dissected inward and outward making two flaps (Fig. 2).

4. Beginning at the top of the abdominal incision, the fat which con-
tains the lymphatic channels is dissected in one mass from the abdomi-
nal fascia. This dissection is carried downward into Scarpa's triangle
on either side. The superficial nodes are removed still imbedded in
the fat if possible. Hemorrhage during the abdominal portion of the

176

BONNEY: GEN IT0-UR1 NARY DISEASES

dissection is slight, but as the dissection is carried over Poupart's liga-
ment into Scarpa's triangle, the superficial epigastric, the superficial
circumflex and the superficial external pudic vessels must be secured
beneath the fat mass as they come through the fascia. If the node
involvement is marked, the growth may extend as one mass through
the fascia lata into the deep inguinal nodes, in which event the fascia is
divided. The sartorius is drawn outward if necessary and the involved
nodes freed from the femoral vessels. Poupart's ligament may be
divided in order to continue the dissection into the crural canal. If
the mass is not continuous from the superficial to the deep nodes, the
fascia lata is divided and the deep nodes freed from the femoral vessels
and removed.

fj^i^Z

Fig. 4. — The wound closed by drainage. The urethra stitched in the peri-
neum. The scrotal wound partially closed in the line of incision and partially by
converting the incision into a lateral wound. (Cunningham.)

5. The patient is then placed in the lithotomy position. An incision
is begun at the root of the penis, passing around both sides, uniting
beneath and continuing along the raphe of the scrotum, bisecting it.
The suspensory ligament is divided and the dorsal vessels of the penis
secured. The penis with the attached fat-mass from the abdomen
and groin is drawn downward. The dissection is carried on until the
attachment of the crura to the pubic rami are met. These are clamped
close to the bone and cut away. The stump is transfixed and tied
and no hemorrhage results (Fig. 3). It is necessary to clamp, transfix
and tie, for the arteries to the crura may otherwise retract and cause
troublesome hemorrhage. Then the corpus spongiosum is freed at a
distance of about f inch in front of the bulb and cut across at this

DISEASES OF THE PENIS AND URETHRA 177

point, unless the membranous urethra seems sufficiently long. It is
better to leave too much than too little urethra. The whole mass,
the abdominal and inguinal fat containing lymphatics and nodes, the
penis and the crura, are then removed in one piece.

(i. The cut end of the urethra is then stretched to the lower part of
the perineal incision, leaving about f inch protruding beyond the surface.
This is cut away about ten days later after the incision has closed. In
this way stricture is less likely to result. A self-retaining catheter is
placed through the urethra into the bladder. A drain is placed in the
perineum, also in the wound of the abdominal skin-apron on either
side, and in the incision in both Scarpa's triangles (Fig. 3).

7. The suturing of the scrotum, so that it is lifted upward, and will
not become soiled by urine, is important.

Primary Tumors of the Urethra. Five cases of solid tumor occurring
primarily in the urethra have been treated at the Mayo Clinic and
form the basis of a study of such neoplasms by Scholl and Braasch.1
Of the 5 tumors, 4 were malignant and 1 was benign. The majority
of malignant growths of the urethra are of epithelial origin and
consequently it is not surprising that chronic irritation and trauma
play a role in their production. A number of cases have been found
in the literature in which chronic infection with its consequent tissue
changes formed a foundation for the development of malignancy. It
would seem that in some cases urethral carcinoma is preceded by a
long period of urinary difficulty, although in others, particularly those
in young men, its development may be rapid. It is stated that in one
case the patient had trouble only three weeks before a definite area
of malignancy was discovered. Traumatic strictures have the same
malignant potentialities as those of infectious origin. A number of
cases of this kind are cited. Malignancy may also develop around
the edges of a urinary fistula. With regard to the age incidence, the
majority of cases which follow long-standing infection occur in men of
middle life and the neoplasm is usually situated at the site of a stricture.
Most of these tumors have a histologic structure similar to that of
squamous-cell epithelioma of the penis, though of a higher degree of
malignancy. In young men the papillary type is more common. They
infiltrate the surrounding tissues rapidly and give rise to remote metas-
tases, which are not common in the squamous-cell type. In the latter,
metastases show a tendency to remain confined to the primary lymph
nodes.

The case of a man with carcinoma of the urethra which followed
a long-standing urethral stricture is reported. He was forty-eight
years of age and was admitted to the clinic in October, 1917. When
a young man he had an attack of gonorrhea and for twenty years a
urethral stricture requiring frequent dilatation. He had a set of
urethral sounds which he used himself. For three months he had had
difficulty in keeping the urethra open and had noticed a gradual swell-
ing in the perineum. His general health was good. A hard, nodular

1 Annals of Surgery, August, 1922.
12

178 BONNEY : GENITO-URINARY DISEASES

mass 2 cm. in diameter was found in the perineum at the penoscrotal
angle. The urethra was markedly obstructed in the region of the
mass, but it was possible to pass a filiform bougie into the bladder.
The stricture was dilated several times, but rapidly recurred, finally
producing almost complete obstruction. At operation a growth 4 cm.
long was found at the juncture of the membranous and anterior por-
tions of the urethra. The involved area was completely excised.
Later complete removal of the penis, testicles and inguinal lymph
nodes was advised, but was refused by the patient. Microscopic
examination showed that the growth was a squamous-cell epithelioma.

Six weeks after the operation the urethra was reconstructed from a
segment of the internal saphenous vein. Two months later the wound
had completely healed, save for a persistent perineal sinus. Three
hundred and fifty milligram hours of radium were applied to the
urethra in the region of the scar through the perineal sinus. The
patient was alive at the end of five years. Whether or not there
had been any recurrence was not ascertained.

Three cases of primary carcinoma of the female urethra are also
reported. The majority of malignant tumors of the female urethra
are squamous-cell carcinomas of a slightly higher type of malignancy
than histologically similar tumors occurring on the cutaneous surface.
They generally respond readily to radium treatment.

The classification of Whitehouse is adopted. He divides them into
two types: (1) An irregular elongated ulceration involving only the
mucous membrane of the urethral floor, usually occurring in the distal
segment; and (2) periurethral tumor having a tendency to infiltrate
surrounding tissue extensively and occlude the urethral canal. In the
first type the growth is generally of a high degree of malignancy. In
the second type ulceration occurs late and fibrosis and hyalinization
are prominent features. The primary neoplasm may grow very slowly
and cause only a few symptoms. Attention may be directed to the
primary focus only by finding a metastatic growth.

The fifth case reported was one of fibroma of the female urethra.
It occurred in a woman, aged twenty-six years, and had been present
at least a year before she applied for treatment. There had been no
urinary disturbance, but straining had often made the growth bleed.
At operation an irregular, lobulated mass attached by a broad base to
the outer half of the mucosa was dissected from the urethral canal.
Histologic examination showed it to be made up almost entirely of
fibrous tissue. Three years later the patient had not had a recurrence
and was in good health.

Pomroy and Milward,1 of Cleveland, report the case of a woman
who was admitted to the hospital for a supposed vaginal hemorrhage,
which had occurred at intervals for a period of five years. The patient
was a colored woman who did not know how old she was, but who
apparently was in the seventies. Examination revealed a condition
which at first looked as though it might be a large carcinoma affecting

1 Surgery, Gynecology and Obstetrics, September, 1922.

DISEASES OF THE PENIS AND URETHRA 179

the cervix of a prolapsed uterus, but which, upon further investigation,

was found to take origin from the external urinary meatus, whence it
extended backward along the posterior wall of the urethra for about
3 cm. As above stated, there was also pronounced downward projec-
tion of the mass. No evidence of disease could be found in the vagina.
The uterus, though senile, was in normal position and the cervix was free
from ulceration. Upon being questioned further, the patient stated
that there had been a small wart-like growth at the urinary meatus
for a number of years before bleeding began. A small piece of the
growth was removed, and was shown by microscopic examination to
be carcinomatous. The pathologist expressed the opinion that the
growth was a caruncle which had undergone malignant degeneration.
Under ether anesthesia five radium needles, each containing 10 mg.,
were inserted directly into the tumor and allowed to remain for twelve
hours. In addition one tube containing 50 mg. of radium, screened
with 0.5 mm. of silver, 1 mm. of brass and 1 mm. of hard rubber was
inserted into the urethral canal and allowed to remain for four hours.
Twelve days after the application was made the mass had shrunken to
one-third its original size. The authors quote Vernot and Parcelier,
who, in 1921, were able to collect only 87 cases, including 1 of their own.
Hypospadias. In 15 out of 17 cases of this malformation, which
came under Madier's1 care, the defect involved the anterior portion
of the urethra and was, therefore, considered proper for the von Hacker
or Beck operation. In 13 cases a perfect result was obtained. One
of the remaining 2 was a failure and in the other it was stated that
"partial cure" was obtained. None of the patients operated upon was
less than nineteen months of age. The author sets a desirable age
limit at two and a half years, believing it is better not to wait until
the children are older, lest erections may tear out the sutures. He
describes his technic as follows. After the penis has been cleansed
and sterilized with tincture of iodine, the prepuce is slit along its anterior
surface and the two angles are clamped along the anterior abdominal
wall, thereby fastening the penis so that the operative field will have
a firm support. While an assistant carefully holds the skin, a rectangu-
lar flap 5 mm. in size is dissected up along the side of the urethra.
The incision is then continued downward along the urethra, which is
made tense, and finally dissected free. The extent of this liberation
will vary in different cases, depending upon the distance of the unnatural
orifice from the end of the glans. The- next step in the operation
consists in passing a bistoury into the hypospadiac opening and cutting
out through the glans. Then the skin flap with the attached urethra
is drawn through this slit and sutured in place by four interrupted
stitches placed at the corners. The longitudinal skin wound is next
closed after the two edges of the corpora cavernosa have been drawn
over the buried urethra. No catheters are used and only a light dress-
ing of sterile gauze is applied. About twelve days are required for
complete healing.

1 Journal de Chirurgie, September, 1921.

180 BONNEY : GENITO-URINARY DISEASES

Niedermayr1 reports 7 successful operations performed according to
the Gesuny two-stage method, which he has found to obviate many
of the technical difficulties of other methods. The first step consists
of making an opening into the urethra through the perineum and
suturing a catheter into the wound. By this means the penile urethra
is kept free from urine.

The plastic operation is described as follows: Two straight parallel
longitudinal incisions 1.5 cm. apart are made from the abnormal urethral
opening up to the glans. These are united at their posterior ends by
an incision encircling the urethral meatus, and the anterior end is
lengthened for its passage through the glans by making a longitudinal
flap on each side of the foreskin with its base at the strip of skin des-
tined for the urethra. A transverse incision is then made on the under
surface of the skin in the coronary sulcus, uniting both sides of the
wound in the foreskin. From this point a subcutaneous canal is made
under the glans, being carried as far forward as the site of the new
urethral opening. Both flaps are then drawn through this canal and
sutured to the edges of the new meatus. The bridge of skin on the
dorsal surface of the glans is cut transversely, the skin freed and the
wounds behind the coronary sulcus are united by circular incision.

A small transverse incision on the dorsum of the penis near its root
is made and through it a dressing forceps is pushed until it appears
behind the glans near the coronary sulcus. A traction suture previously
placed over the scar-like band behind the glans on the dorsal surface
of the penis is drawn through the canal thus made so as to bring the
glans out in the upper opening near the symphysis. This carries the
penis up toward the abdomen, to which it is temporarily fastened by
sutures passing through the inner preputial flap.

In young children continuous catheterization is employed. In older
ones the catheter is clamped and allowed to drain the bladder only as
they feel the desire to urinate. At the end of two weeks the catheter
is removed. In three or four weeks the penis is freed from the abdo-
men by a short transverse incision behind the glans and two longi-
tudinal incisions toward the scrotum, including enough skin to cover
the dorsum of the penis. A slight plastic operation may be necessary
to close the cutaneous defect.

A plastic operation on the urethra by the use of a segment of the
saphenous vein is reported by Riese.2 The patient, a man aged forty
years, had been operated upon in 1917 for a resilient stricture. In
February, 1920, abscess and fistula developed. A few weeks later he
came under Riese's care and on March 8, 1920, operation was under-
taken. Through a perineal incision, firm cicatricial tissue, extending
back to the neck of the bladder was found, but the urethra could not
be isolated. Through a median suprapubic cystotomy a catheter was
passed through the internal urinary meatus down into the membra-
nous urethra, which was opened over the tip of the instrument. All of
the cicatricial tissue was excised, after which a piece of saphenous vein

1 Miinchen. med. Wchnschr., June 24, 1921.

2 Deutsch. med. Wchnschr., September 22, 1921.

MISCELLANEOUS 181

10 cm. long was introduced on a fine catheter and fastened both above
and below by means of sutures. The suprapubic vesical wound was
also drained. Urine was discharged through both catheters. After
ten days the one in the urethra was taken out and ten days later tin-
other was removed from the wound in the bladder. The bladder was
irrigated once daily through a catheter passed into the incision. Twenty-
four days after the operation boric acid was introduced into the urethra,
whereupon it was found that there was a small fistula at the proximal
end of the implant. A retention catheter was again introduced. At
the end of five days urination was normal without any discharge of
urine through the perineum. The patient left the hospital three and
a half months after the operation. At the end of a year a 17-French
could be passed.

This method was reviewed in Progressive Medicine a number of
years ago, and occasionally since that time cases have been' recorded
in the literature. Kiese expresses the opinion that even if the segment
of vein fails to become epithelialized a permanent urethra can be formed.
In his ease he thinks that absorption eventually took place.

Another successful case of this kind has been reported by Remete.1
His patient had an impermeable stricture. The callus was excised and
a piece of saphenous vein 8 cm. long was implanted between the ends
of the divided urethra.

Impacted Urethral Calculus. Impacted calculus in the urethra is an
apparently rare condition, producing inflammation, edema and pro-
liferation of the adjacent tissue, which locks the stone in place and
renders its dislodgment impossible except by mechanical manipulations
which must be promptly resorted to in order to prevent obstructions
to the urinary flow.

In a recent paper P. A. Jacobs2 describes a technic which he has found
very satisfactory, inasmuch as it does not traumatize the urethra.
Fifteen or twenty- olivTe-tipped whalebone bougies are inserted into
the urethra up to the point of obstruction and are manipulated one
by one until they are made to pass a little beyond the stone and to
surround it, when they are all grasped together and pulled out. The
lumen of the bougies is practically obliterated at the olive-tipped end
and when they are pulled out the calculus is caught as if in a cradle,
the bougies acting as a covering to the rough surface and thus preventing
injury to the mucosa during withdrawal. A case in wmich the stone
was successfully removed by this method with practically no discomfort
and only trifling bleeding is reported.

MISCELLANEOUS.

Venereal Granuloma. In Progressive Medicine for 1917 this form
of veneral disease, at that time supposed to be confined to tropical
countries, was discussed, special attention having been given to the
investigations made in Brazil by Aragao and Vianna and Desouza

1 Wien. Klin. Wchnschr., September 22, 1921.

2 Journal of the American Medical Association, September 10, 1921.

182 BONNEY: GEN ITO-URI NARY DISEASES

Araujo. During the five years which have elapsed since the review
of this subject a number of cases have been reported in the United
States, many of them occurring in patients who had never been in the
Tropics. Thus, in 1920, Symmers and Frost1 reported 2 cases from
their service in Bellevue Hospital, New York, and, in 1921, Campbell2
recorded 3 other cases from the same institution. Last year, also,
Reed and Wolfe3 reported cases which they observed in New Orleans.

Parounagian and Goodman4 have recorded the following interesting
case in which remote regions of the body were involved:

A man, white, an American, aged thirty-two years, presented a mass
of hypertrophic, foul smelling, discharging, red papules and nodules,
involving the region of the groins, exending across the pubes downward
along the femoro-scrotal clefts, circumscribing the anus, and invading
the depression between the buttocks and the legs. In the last mentioned
region the clinical appearance was identical with that pictured by
De Souza Arauja in a South American case. Furthermore, the patient
(who had never left New York City) presented similar lesions on the
lips and the side of the neck.

The authors could find only one similar case recorded in the literature.

In a later paper, Goodman5 describes a number of other cases of
venereal granuloma which he has seen in New York.

At the January, 1921, meeting of the Philadelphia Genito-Urinary
Society, Alexander Randall presented a number of patients from the
venereal wards of the Philadelphia Hospital, who showed lesions resem-
bling in all respects those described as inguinal granuloma. Injections
of antimony given to some of these patients had produced epithelializa-
tion of the lesions. Randall stated at that time that his interest was
aroused by the publication of Symmers and Frost's paper and that he
began the study of a class of cases presenting similar lesions which is
always to be found in the Philadelphia Hospital. In a recent article
published in conjunction with Small and Belk, Randall6 presents an
exhaustive study of his cases. He states that in his mind there is no
doubt but what this disease has been endemic in the vicinity of Phila-
delphia for at least fifty years, and cites evidence to show that it has
been present in the wards of the Philadelphia Hospital for fully twenty-
five years. About 15 patients affected with such lesions, and almost
all of whom are negroes, are admitted to the hospital each year and
with 1 exception all of the cases which these authors studied were
in negroes. In all of these cases, but that of the white man, rapid
and apparently complete cure was obtained by the antimonial
injections. There were 2 recurrences, both of which, however, were
attributed to neglect of treatment. Both patients entered the hospital
the second time and were cured as the result of further treatment.
It is stated that no alarming symptoms followed the injections of

1 Journal of the American Medical Association, 1920, vol. 74.

2 Ibid, 1921, vol. 76.

3 New Orleans Medical and Surgical Journal, 1921, vol. 74.

4 Archives of Dermatology and Syphilis, May, 1922.

5 Journal of the American Medical Association, September 2, 1922.

6 Surgery, Gynecology and Obstetrics, June, 1922.

MISCELLANEOUS 183

antimony and that do changes in the blood or urine could be
detected after its use. Three patients who were emaciated and
anemic gained in weight and showed an increase in hemoglobin
after their local lesions had improved. At first treatments were
given daily, an injection of 0.04 being administered until symptoms
of intolerance were manifested, which, as a rule, occurred about
the tenth day. Then the injections were given at intervals. Often it
was possible to give one every second day. The symptoms of intoler-
ance consisted of pains in the joints and stiffness in the muscles, and
were most noticeable early in the morning. Tartar emetic was the
drug used in the majority of cases, but a synthetic antimonial com-
pound, sodium-antimony-thio-glycollatc, prepared by Abel, of the
Pharmaceutical Department of the Johns Hopkins Medical School,
was used with brilliant results in 1 case. The highest dosage of tartar
emetic required to bring about complete healing was in a female patient,
who had thirty-two injections, equivalent to 1.96 gm. One patient,
having a lesion the size of a silver quarter, was cured by four injections.
It is stated that healing commences within forty-eight hours after the
first injection, and that daily progress can be noted as the treatment is
continued. Epithelial proliferation starts at the edges and rapidly
spreads inward, while often isolated islets of epithelium in the midst of
granuloma start proliferation in the center of the lesion. The typical
encapsulated organism could not be demonstrated in smears taken
after the second or third dose of antimony. Following the advice of
Vianna, who introduced the antimony treatment of venereal granu-
loma, the authors have endeavored to get all their patients to take at
least twelve injections. If the sores heal before twrelve have been
taken, they continue to give one each week until the full number have
been administered.

Organisms corresponding to those described by Donavan, Aragao
and Vianna,. and others, were demonstrated in 12 cases. In the other
4 of the series no laboratory examinations were made. The organism
is a Gram-negative encapsulated bacillus, which the authors believe
does not possess sufficiently distinctive characteristics to warrant its
separation from other members of the group; and they quote Aragao
and Vianna, who formerly believed that they had isolated a specific
bacillus, which they named calymmato-bacterium granulomatosis, to
the effect that further studies have left them doubtful as to whether
a new and specific member of the group can be established.

In 3 cases Randall and his associates w7ere able to grow cultures of
an encapsulated bacillus obtained from the lesions. They also con-
ducted some experiments upon animals. It was found that lesions
produced by the strains of granuloma origin, and those produced by
different members of the group were identical. Intraperitoneal inocu-
lations of mice and guinea-pigs proved rapidly fatal, but cutaneous
inoculations failed to produce any lesions. The subcutaneous inocula-
tion of rabbits resulted in the formation of abscesses which ruptered
spontaneously and left ulcers which healed spontaneously in from
three to seven weeks. Their gross appearance did not resemble

184 BONNEY: GENITO-URINARY DISEASES

granuloma, although histologic examination of their walls showed tissue
which could not be differentiated from that of typical granulomata
in man.

The authors describe the lesions as follows: The typical lesion is
a flesh-red exuberant overgrowth of soft granulation tissue, having
absolutely no similarity to an ulcer. Its center appears slightly
depressed, but the edges overlap the apparently healthy skin margin.
Exudate is scant, mucoid in character, of a nonoffensive odor, and
when wiped with gauze is easily removed, leaving a clean, blood-red
surface similar in every respect to a large area of healthy granulation
tissue as seen in clean surgical wounds. The later lesions may show
tendencies toward healing at some points, while spreading in others,
but this occurs only when flat nonchafing surfaces are involved. The
most frequent location is in the groin, extension taking place as far
backward as the anterior-superior spine of the ilium and downward
through the fold of the groin to the perineum, whence it may work
its way backward and upward to the buttocks. In the female the labia
majora are most frequently involved. Extension may take place the
same as in the male. The granuloma is practically painless. Second-
ary anemia is present in cases of long duration, and loss of weight has
also been noted. The authors have had 4 cases in males in which the
lesion was limited to the groin, 2 with penile involvement, 1 limited to
the anal region, and the remainder with multiple involvement, includ-
ing the perineum.

Value of Drugs in Urology. In this article Hugh H. Young1 publishes
an analysis of the answers to a questionnaire which he sent to thirty
well-known urologists concerning seventy drugs that are recommended
in the treatment of genito-urinary diseases. It was requested that
they indicate only those drugs which they had found useful in their
practice. Only 18 out of the list of 70 were approved by 50
per cent of the urologists; 30 per cent gave approval of 25
of the drugs. Hexamethylenamin stood first in the list, and silver
nitrate second. Potassium permanganate was given the third place
and argyrol the fourth. Young makes the comment that silver nitrate
is indispensable and that permanganate and argyrol, while known to
have very weak antiseptic properties, are non-irritating. It might
well be added that permanganate is also cleansing, in that it decomposes
secretions and produces a slight serous outflow. It is remarked that
the rest of the total list of drugs bore silent testimony to the fact that
the urologist is not a polypharmacist and many widely heralded and
much-advertised preparations have not proved acceptable.

1 Journal of the American Medical Association, October 22, 1921.

SURGERY OF THE EXTREMITIES, SHOCK,
ANESTHESIA, INFECTIONS, FRACTURES,
DISLOCATIONS AND TUMORS.

By WALTER ESTELL LEE, M.I).

The present practice of surgery has not eseaped the universal dis-
trust of things social, economic and politic. Bernard Shaw,1 in an
address to a meeting of medical men, protesting against the knighting
of Mr. Parker (the bone-setter), calls attention, in his usual paradoxical
vein, to the "advantages of being unregistered," or, as we would say,
unlicensed.

"This title was usually given in medicine to the heads of the profes-
sion. Here it had been bestowed on a man who was not only unregis-
tered but unqualified. He had no recognized medical training but
'had learned his business' from another bone-setter. The faculty
was inclined to regard such persons as ignorant. Unfortunately, they
got relatively as many cures as the qualified, and often obtained their
best results when the latter had failed. To the -public there had always
been a glamor about the unqualified man— probably because he dared to
charge more than his qualified rival. His popularity had increased so
much of late that patients would now frequently run the whole gamut
of osteopaths, masseurs, Christian scientists and psychotherapists
before turning to the qualified physician."

What was the cause of this waning faith? He attributed it to the
narrow-mindedness of the general medical council. Its main failing
was that it consisted entirely of physicians. Such a system tended to
a medical autocracy, and the community, for whom the physicians
worked, had no opportunity of expressing its views on medical organiza-
tion and conduct. The remedy lay in constituting the council mainly
of members of the informed public, with physicians as assessors. Such
a body would be in a position to effect several needed reforms in medical
practice and education. First was the question of admission to the
profession. It was absurd for any body of men, whether physicians
or bottle-washers, to say to a man, "You shall not enter our profes-
sion." That was for the general public to say. Next came the prob-
lem of medical education. The most needed reform was lengthening
of the curriculum, but this could be compensated for by cutting out
certain unnecessary parts of subjects which were taught at present.
The smattering of science, for instance, in which the medical student
was grounded, was unnecessary. Medicine was not a scientific profes-
sion. Yet such was the effect of the so-called scientific training that

1 Journal of the American Medical Association, August 12, 1922, p. 572.

186

LEE: SURGERY OF THE EXTREMITIES

) hA-J~^.:;

the surgeon tended to regard all disease problems as mechanical, the
physician to regard them as chemical; whereas, such problems were
vital.

Perhaps this is not all true, but it is right in that the real trouble
lies not with the public but in the profession itself. The time has long
passed when we can complacently say this lack of confidence is entirely
due to the inability of the patient to appreciate our methods and our-
selves. It is time for us to " stop, look and listen," as the railway signs
.have it at dangerous crossing, and not at the distrusting public but
| at ourselves. A young woman, under thirty years, who was recently
referred from one of the smaller community hospitals, now so common
in our country, will serve as an example (we will admit an extreme one)
of the cause of the public's distrust. After a cholecystectomy and
appendectomy, a bilateral salpingo-oophorectomy, a myomectomy and
finally a hysterectomy (all separate operations) the patient was sent
to the hospital with the request that we anchor her movable kidneys
because she was unrelieved of her symptoms.

Tarnowsky1 indulges in a very useful introspective study which he
calls " the fad for pseudoscience."

Blind indeed must be the present-day yEseulapian who does not
sense the changing attitude of many laymen toward our profession.
With all due allowance made for the endemic reform wave, the com-
petition of pathies and isms, the desire for "something new" and the
unmistakable tendency toward compulsory state health insurance, the
fact remains that our patients are demanding that they be more fully
taken into consideration as individuals and not as cases, and that
they be subjected to lines of treatment based on natural laws. Equally
blind is the doctor— specialist or general practitioner— who, frankly
comparing notes with his colleagues, has not sensed a faint, but never-
theless unmistakable, awakening to a fuller realization of the truth as
at present understood, based on rational knowledge of the basic sub-
jects of our medical studies.

Why is there so much medical unrest, so much open or hidden dis-
satisfaction among an ever-increasing percentage of the medical pro-
fession? It is still fashionable to blame the World War for everything;
certain it is that many of our fellows returned from camp or overseas
to their more or less thoroughly disrupted civil practices with new
ideas, new thoughts and many doubts regarding the value of certain
surgical or medical "sheet-anchors," to which they had clung through
the years as barnacles to a ship's bottom— barnacles being periodically
scraped off whenever a vessel is dry-docked for repairs. Never in the
past quarter of a century has there been such dire need of medical dry-
docking as at present.

May all this mental doubt not be due to the fact that the medical
"Intelligentsia," to use a new popular term, has come to realize that
it knows too much and too little of the forces which preside over the
state of balance which we call health and of the biochemical changes

Journal of the American Medical Association, vol. 76, 859.

LEE: SURGERY OF THE EXTREMITIES 187

which occur in departures from the normal? Happy indeed is the
physician who can still prescribe tincture of ferric chloride in erysipelas,
or apply a beautifully finished and carefully dated plaster-of-Paris cast
over a non-redueed fracture with a clear conscience; thrice happy and
to be envied is the still more venerable practitioner who has definite
specifics which can, in the twinkling of an eye, "scatter" inflammation
internally or externally.

Methods of treatment have ever changed with— not ahead of— the
evolution of knowledge; but, whereas in the past the individual's
gastro-intestinal tract could rebel and eject the offending potion per
cius n df a mlcs —either proximal or distal — Nature is now given no chance
of asserting itself because we either plunge our medication intramus-
cularly, intravenously or intrathecally, or else apply emanations whose
potentiality for harm, when injudiciously used, is rarely mentioned in
scientific discussion.

Are there no voices in the wilderness sending out a warning cry
which will cause the thoughtless among us to pause and think before
accepting new curios and applying them to the alleviation of disease?
Yes, thank Heaven, a few courageous physicians have recently made
themselves heard in no uncertain tones. Read Harvey Cushing's
presidential address, delivered before the Society for the Study of
Endocrinology.

In a recent number (April, 1921) of the Armies de la Faculiad de
Medicina of Lima, Peru, is the bold statement made by Escomel to
his students:

Each individual exhibits idiosyncrasies or special predispositions to
immunity or anaphylaxis; in his own blood-stream are marshalled the
forces of reaction, and it follows therefore that his serum contains all
of the biochemical elements, either in process of transformation or
reaction, with which he will defend himself against bacterial invasion
regardless of the latter's species, strain or morphology. It is, therefore,
self-evident that each individual harbors a polyvalent serum, which
belongs to him exclusively and which is capable of exerting the maxi-
mum of benefit or of curative value on himself alone. Is this not
tantamount to the frank admission that departures from the normal,
i. e., diseases, tend to be overcome by means of a total, integral auto-
genous serum? Even granting that a very few so-called specific anti-
toxins, such as those of diphtheria or of tetanus, have proved their,
prophylactic or curative value, there are valid objections against the
use of serums obtained from zoological species which differ more or less
widely from man; is it not reasonable to ascribe to this fact the majority
—if not all— of the hemolytic and anaphylactic phenomena which
have sometimes even terminated fatally? Does not the use of a het-
erogeneous antitoxin explain the not infrequent failures which in all1
probability ahvays occur in polymicrobial infections?

With equal truth, Escomel might have added that the polyvalent
commercial antitoxins represent a thoroughly inaccurate and unscien-
tific attempt to meet this polymicrobian type of infection. Inaccurate
because the individual's bacterial flora are rarely, if ever, cultivated

188 LEE: SURGERY OF THE EXTREMITIES

and identified prior to the use of these "shotgun" infections; unscien-
tific because, even if such cultures were made, they could not accur-
ately indicate the relative present toxicity of the various strains in the
individual and hence determine the percentage of each, and every
"specific" antitoxin which the manufacturer so glibly puts up and
markets for the convenience of our inert gray matter. Is not Pierre
Duval's recent attempt to treat appendiceal infections by means of
polyvalent stock vaccines which include all "probable" bacterial
strains— from Streptococcus hemolyticus to the colon bacillus, with
Bacillus catarrhalis and a few other varieties thrown in for good measure
—a distinctly retrograde one, scientifically speaking? Finally, are
there not grave doubts in the minds of many thoughtful men, internists
as well as surgeons, that antitoxin reactions are merely non-specific
protein reactions? Is not the present wave of " milk-serum "injec-
tions a tacit admission of the truthfulness of the foregoing suspicion?

The craze for novelty, love of the pseudomiraculous and fear of not
finding himself "in the procession" are prompting too many of our
colleagues to discard methods of treatment which have stood the test
of time for pseudoscientific measures which appeal to the imagination
or inherent love of mysticism of our patients; and we, the conserva-
tives, are called on to repair the often irreparable damage done by the
faddists.

How can we teachers protect the present and future graduates in
medicine from these fatal tendencies? Can we not more strongly
impress on them the reliability of basic principles of anatony, physi-
ology and biology, and the unreliability of commercialized read-to-use
methods which are surely undermining our standing in the body social?
Are we sufficiently emphasizing the curative forces of Nature in our
lectures or demonstrations— whether they be on general or special
topics of the healing art? Is it not the duty of teachers— either in the
fundamentals or in the specialties— to tell our students what Nature,
unaided, will do or try to do in any given departure from the normal
in order that they may learn to avoid antagonizing the forces of Nature,
which we are at last beginning to understand and appreciate at their
true value? Is it not time for us to clean house, to teach our students
'along rational lines, discarding the many fetishes we have so long clung
to and cautioning them against new theories until the latter have
become facts? Both in surgery and in internal medicine we have often
failed to give Nature full play, and the undoubted success of the host of
pathies and pseudoreligious sects with which we are waging a more or less
futile and undignified warfare is the natural reaction against our stubborn-
ness.

Will not our position in the body-social be strengthened rather than
weakened when we drop the mantle of mystery with which we at present
surround ourselves and frankly take the public into our confidence?
The time will never arrive when Nature cannot be helped in a myriad
of logical ways and medical men will ever be in demand; the trouble
with our profession is that it persists in too much meddlesome therapy—
using the term in its broadest sense— to the detriment of Nature. We are

MEDICAL EDUCATION 189

losing sight of "the patient himself" -to quote from Hugh T. Patrick's
superb article on the subjecl and many of ns arc substituting machine-
made diagnoses for clinical acumen, read-to-use advertised remedies for
intelligent cooperation with Nature, fads for facts.

Let's drydockl

Medical Education. We would suggest that a faulty system of
medical education in the past and present makes such conditions pos-
sible and that any hope for a change lies in a reorganization of medical
education.

de Schweinitz,1 in his presidential address before the American
Medical Association discusses these necessary changes at length.

Medical education, omitting from consideration premedieal instruc-
tion, naturally divides itself into: (a) Undergraduate or pregraduate
education; (b) graduate or postgraduate education; and (c) university
extension education, that is, community service.

1. Pregraduate Education. The standards have been raised to an
acceptable height, and a curriculum suggested after conscientious and
sometimes meticulous study and thought. But emanating from edu-
cators and from the student body there is a justifiable and well-known
criticism, expressed almost epigrammatically by one of them, unusually
well balanced and among the favored ten: "We get our instruction in
packets. The students never realized, or more properly, were never
made to realize," he proceeded, "the proper relation, for example, of
anatomy and physiology to the general scheme, until the ' clinical year '
arrived, and by that time the packet had grown old and musty."

As has been clearly stated by Henry S. Pritchett, "These funda-
mental sciences should be taught, not as something separate from
medical practice, but as part of it. The fiction that the medical student
can be prepared for medical practice by learning a mere fragment
from every field of science ought to be definitely given up." Moreover,
it is evident, as has often been pointed out, that instruction in these
fundamentals— physiology, anatomy and pathology— is too widely,
perhaps too strictly, separated from clinical training, which should be
introduced into the curriculum at a time sufficiently early to make it
the important medium through which the student shall acquire a
familiarity with the practical application of these subjects. These
should keep pace with the other branches of the tree of knowledge,
being neither lopped off nor allowed to wither.

In short, looking at this matter from any standpoint, if the student
is to be properly fed educationally, he must have a much more evenly
balanced diet, and, in the words of a great educator, "Reform of the
curriculum of the undergraduate medical school is one of the most
pressing questions of present-day medical teaching."

2. Graduate Teaching. That even today, except in limited supply,
opportunities for graduate instruction, greatly needed and eagerly
sought, are not commensurate wTith the rank they deserve and require,
is a matter of common knowledge and of regret. To be sure, for many

1 Journal of the American Medical Association, 1921, 78, 1583.

190 LEE: SURGERY OF THE EXTREMITIES

years postgraduate courses have been available, and some of them have
been conducted, especially those which pertain to the "specialties,"
on a high plane and have achieved good results; but, in the main, it
must be admitted that they have been unsatisfactory. Indeed, only
too frequently men have been certified as qualified along certain lines
of medical and surgical practice after inadequate instruction, and they
have been stamped, as it were, with approval unjustified in the circum-
stances.

Time does not permit an analysis of the types of graduate medi-
cal courses which are, and have been, in operation. We are all well
acquainted with the methods (as summarized by Meeker) of obtaining
graduate educational equipment through the medium of clinical and
laboratory assistantships, of personal courses, of attendance on clinics
recommended from a central registration office (London type) of short
"polyclinic courses" (too often imperfect and superficial), of brief
organized university courses (somewhat similar to the polyclinic courses,
but with the advantages of university surroundings), and of assistant-
ships under university and foundation control. None of these plans,
despite certain excellent qualities which pertain to most of them,
meets the requirements of graduate instruction as it should be con-
sidered at the present time, in the sense of taking place in a school of
graduate medical education, and, moreover, in one in cooperative
affiliation wi+h an undergraduate medical school, and preferably with
one which is a department of medicine in association with a university.

In the last-named circumstances the graduate school of medicine
becomes part of a university system, as Meeker has said, and should
be so organized that it can take advantage of all other available or
required medical and scientific instruction, hospital or laboratory
and industrial plants. Under such conditions a truly comprehensive
plan of graduate medical education is possible, founded on the best
types of courses, correlated with the facilities which have been named,
and leading to a certificate or suitable degree. That such a plan is
not " too comprehensive " and can be carried out with gradually increas-
ing satisfaction to those concerned, is evident from the fact that at least
in one university it is in full and satisfying operation and has made a
contribution of the highest value to medical education. There is no
reason why, in the near future, similar methods of graduate school edu-
cation should not be active in all our larger medical centers. Xo
appeal can be too urgent for sympathetic, moral and financial support
for such a type of graduate medical education.

3. Medical Extension Education. In recent times a rather widespread
disquietude has arisen lest the supply of doctors should become inade-
quate. From the numerical standpoint, as a recent investigation has
shown, this fear may be dismissed. But the geographic distribution
of physicians is a problem that may well excite concern. It would
seem that the rural districts, villages and smaller towns are being
drained, on the one hand, and, on the other, are failing to receive
their just quota of the graduates in medicine, owing to the attactions
and greater facilities— laboratory and hospital— of the larger towns and

ANTHRAX 191

cities, from which the physician with a modern training not unnaturally

declines to be separated. Also, poor economic conditions add their
deterrent influence.

The recent graduate stationed in the country, lest he suffer a disas-
trous eclipse, must keep in practical touch with new developments in
diagnosis and treatment, and, moreover, his patients are insistent that
he shall do so. He cannot leave his duties to seek such information
and instruction in distant "centers;" hence methods are being devised
whereby such facilities shall be brought to him in an endeavor to satisfy
the practitioner's laudable ambition and his requirements, as well as
the desires of his clientele.

In some of our states, South and West, and also recently in the
East, annual courses have been organized, conducted through their
respective university extension services, in cooperation writh the county
societies alone, or with these societies aided in certain respects by the
state boards of health. Primarily it should be ascertained in which
districts such courses are desired. Information in this respect may
well be secured by the committees on scientific work of the state societies,
as, indeed, in certain commonwealths it has been and the courses sug-
gested after consultation with the local or county society, and their
membership because it is from them that the invitation comes.

Reference has been made to graduate medical courses based on uni-
versity-extension services, as they are already in operation, notably in
one state. Therefore, when a university system includes a school of
graduate medicine it can carry its educational efforts to groups of
physicans found in selected localities. Such endeavors have as yet
not attained their full development, and for the most part, at least, are
in their formative stage. A comprehensive program with respect to
this type of education is being studied, on request, by the dean of the
Graduate School of Medicine of the University of Pennsylvania and a
committee appointed by the state medical society.

Anthrax. An editorial in the Journal of the American Medical Asso-
ciation, 1922, 79, 43, calls attention to anthrax in man as a disease
of such serious moment that its menace scarcely needs to be empha-
sized. The more recent outbreaks of cases attributable to infection
from shaving brushes have tended to arouse a greater interest in the
subject and to awaken public health officials in many places from the
apparent lethargy in regard to it. Anthrax in man is most frequently
encountered among workers on hides, hair, bristles, wool, etc., and in
laboratory workers, veterinarians, meat inspectors, farmers, cattlemen
and butchers.

In Pennsylvania, according to the investigations of Smyth and
Bricker,1 slightly more than 8 per cent of the 7458 men engaged in
57 cattle-hide tanneries were directly exposed to anthrax risk during
the period under consideration. In 19 goat-skin tanneries, employing
nearly 6000 men, somewhat more than 7 per cent were directly
exposed. Thus, a total exceeding 1000 men, or not quite 8 per

1 Analysis of One Hundred and Twenty-three Cases of Anthrax in the Pennsylvania
Leather Industry, Jour. Indust Hyg., June, 1922, 4, 53.

192 LEE: SURGERY OF THE EXTREMITIES

cent of the employees, was exposed to the serious danger. Of these,
at least 119 contracted anthrax in the course of the twelve years
included in the Pennsylvania study, and 4 more cases developed in
those handling raw hides or skins, making 123 cases in all, or more than
11 per cent of the number of directly exposed tanners. Seventy-three
of these cases were due to the handling of cattle hides, and 50 to the
handling of goat skins. One-fifth of the patients died.

This is not the place to discuss the comparative danger of hides from
different sources. The fact that during a five-year period a yearly
morbidity-rate is on record of almost 2 per cent from anthrax among
directly exposed tannery employees suffices to point to the lesson.
Hides and skins imported into this country are supposed to come in
under quarantine unless accompanied by a consular certificate stating
that they are from a district free from anthrax. But the experience of
Smyth and Bricker agrees with that of others to the effect that this
certification is worse than useless, since it merely establishes a false
sense of security among the tanners and freight handlers. It is stated
that anthrax has been contracted from the handling of both dry and we^j
salted hides and skins, and from both certified and uncertified stock,
and anthrax bacilli have been isolated from both. It is high time to
give more serious consideration to the anthrax problem. The tanneries
must no longer be allowed to receive anthrax-infested raw stock.

Symmers1 holds that the experience of recent years indicates that we
must relinquish certain conceptions that have been bequeathed to us
concerning the therapy of anthrax in man. It is now known that the
pustule of cutaneous anthrax frequently heals spontaneously if it is
left to its own devices and not subjected to operation or cauterization,
either of which may precipitate septicemia. Anthrax septicemia, on
the other hand, is commonly regarded as a form of infection that is
practically always fatal. As a matter of fact, of all the septicemic
diseases, it is the one with which we are best prepared to deal, namely,
through the use of immune serum. The literature of medicine contains
references to 6 cases of cutaneous anthrax with bacteriologic proof of
disseminated infection, in which recovery followed the intravenous
use of antianthrax serum. A seventh is described in this paper. The
same method of treatment would appear to be applicable to the septi-
cemic forms of pulmonary and intestinal anthrax, although Symmers
has not been able to find any reference to its employment in such cases.

The localized cutaneous lesion of anthrax, when fully developed,
presents an appearance scarcely to be mistaken for that of any other
disease. It is an ugly affair to look upon, painless and possessed of
vicious potentialities. It is characterized by a dirty brownish eschar,
scattered over and surrounding which are numbers of pinhead-sized
silvery vesicles, the whole set in the midst of an area of swelling which
may remain within moderate bounds or assume such enormous propor-
tions that when the pustule is situated on the face or neck the eyelids
are closed and the tissues of the upper part of the chest are thrown

i Annals of Surgery, July, 1922, No. 6, vol. 75.

ANTHRAX 193

into large edematous folds. The swelling is due to the presence of a
semigelatinous substance -anthraeo-mucin—which is inimical to the
growth of the anthrax bacillus and which represents a defense reaction

on the part of the tissues and should be left alone.

While the anthrax pustule itself offers a forbidding aspect, the appear-
ance of the patient, on the contrary, is apt to give one the impression of
extraordinary tranquillity, even though his blood maybe swarming with
anthrax bacilli. For this reason, the only really justifiable attitude for
the physician to assume is that every anthrax pustule from the outset
is attended by the dissemination of bacilli in the blood, and to treat
the patient on this assumption until the result of the blood culture is
known. It is, at best, an error on the safe side. In artificial culture
media the anthrax bacillus grow with facility and positive cultures
may be sometimes secured within twelve hours, always within twenty-
four hours. A negative result in twelve hours should never be accepted ;
a negative result in twenty-four hours need never be rejected. In the
meanwhile the administration of serum is a harmless procedure, and,
in the event that anthrax septicemia exists, valuable time will have
been saved.

1. Every anthrax lesion of the skin or elsewhere should be tentatively
regarded as attended by generalized infection until the result of the blood
culture proves the contrary.

2. In no circumstances is it justifiable to tamper with the anthrax
pustule— incision, excision, cauterization or similar treatment is danger-
ous, and may be followed by anthrax septicemia. The only permissible
form of local treatment consists in the injection at the periphery of the
pustule of broken doses of antianthrax serum at intervals of four or six
hours, each injection not to exceed a total of 10 or 15 cc. Failing this,
it is better to cover the lesion with a bit of sterile gauze to collect the
secretions, but otherwise to leave it absolutely alone.

3. The most dependable routine method in the treatment of the anthrax
pustule is: (1) To isolate it within a barrier of antianthrax serum
subcutaneously injected every four hours; (2) to inject intravenously, at
once, a sterilizing dose of 150 or 200 cc of serum; and (3) to supplement
this by the intravenous injection of 40 cc every four or eight hours. If
the blood culture is negative at the end of twenty-four hours the intra-
venous use of serum may be discontinued, the local injections being
kept up until the pustule is free from bacilli, or at least until involution
forms occur in the stained films. In anthrax septicemia the liberal use
of antianthrax serum intravenously, if commenced in time, is capable
in many instances of sterilizing the blood with astonishing rapidity, and
in septicemic cases the routine just outlined may be followed until the
blood cultures are negative.

Regan1 reports 8 cases of anthrax successfully treated in the last
two years with Eichhorn antianthrax serum, given by local injection
around the lesion and general injection into the circulation, without
any fatalities. The acute inflammation disappeared from the second

1 Journal of the American Medical Association, December 17, 1921, p. 1944,

194 LEE: SURGERY OF THE EXTREMITIES

to the sixth day of treatment, the eschar separated from the twelfth
to the twenty-first day, and the wound healed from the twentieth to
the thirty-second day. No sequelae were noted in any instance, and the
scar left was so minute as to pass unnoticed. The acute stage was
over within a week.

Serotherapy of Anthrax. Biancheri1 protests against incision of
the focus as intramuscular or subcutaneous injection of the antiserum
has always proved effectual in his experience, unless the patient was
moribund when first seen. He injects 60 cc at first, and then 20 cc
each day. After the local inflammation has entirely subsided, he excises
the eschar to hasten the healing. Conti, on the other hand, excises the
lesion completely with a deep circular incision. The mortality was
3.33 per cent in 60 cases treated in this way, while it was 20 per cent
in 20 treated by a crucial incision.

Human Actinomycosis. Although the disease "lumpy jaw" in cattle
was first described by LeBlanc in 1826, it was not until 1877 that Bol-
linger and Hartz discovered the specific microorganism and gave to it
the name actinomycosis bovis. Israel and Wolff shortly afterward
isolated the same organism in pus of an empyema in the human subject.
Since the discovery of Wolff and Israel, there have been many and
varied human manifestations of this disease reported in the literature.
This is especially true for the past decade due in a large measure to the
fact that many of the earlier cases went undiagnosed, though some
investigators believe that this disease is gradually becoming more
prevalent in this country.

Mattson2 has studied 44 cases at the Mayo Clinic. Vander Veer3
reports 1 case.

There is but one true species of microorganism capable of producing
actinomycosis in man and lower animals, and this is the one isolated
by Wolff and Israel, and later more fully described by Wright.

There is no convincing clinical evidence supporting the theory that
this organism is a normal inhabitant of the oral cavity and gastro-
intestinal tract of man.

There is much clinical and biologic evidence that this microorganism
has its source outside of the human body and is capable of a dual exist-
ence: first, as a saprophyte in old sod soil from which it gains access
to grains and grasses, and through this medium or intermediary host,
so to speak, it becomes capable of infecting man and lower animals.

In order for infection to take place, two things are necessary: (1) An
abrasion of the tissues; (2) the fungus must in some way be brought
directly in contact with this abrasion.

Animal-to-man infection is far more common than we have been led
to believe it was by earlier investigators.

Human actinomycosis is not a rare disease, but a disease which is
often overlooked or incorrectly diagnosed.

Every inflammatory swelling of chronic or subacute nature with

1 Policlinico, Rome, May 29, 1922, Nos. 22 and 29.

2 Surgery, Gynecology and Obstetrics, 1922, 34, 482.
» Medical Record, February 18, 1922.

MYCETOMA 195

persistent and recurring sinus formation should be cart- fully investigated
for this disease.

A negative smear, on first examination does not rule out infectioE
as the fungus, in the presence of mixed infection, is often very difficult
to find.

The disease should always be kept in mind in every ease of atypical
pulmonary tuberculosis and should be looked for in eases suffering with
chronic purulent bronchitis or bronchiectasis.

Prognosis. In neck and jaw cases the prognosis is good. Of the
14 cervical and 7 jaw cases in this series, 12 reported themselves as
entirely cured; 7 were improving, but not entirely well. Skin cases,
while stubborn, eventually clear up under vigorous treatment. The
mortality in appendiceal cases was 100 per cent, all having died after
being under treatment for six months to a year. The pulmonary form
in this series was just as fatal as the appendiceal, aside from the rare
case of bronchial infection, which was still living twenty years after
infection took place, though the patient was much annoyed by a
chronic purulent bronchitis.

Treatment. This seems to be one disease in which potassium iodide
is specific. Heroic doses, however, are necessary, as even moderate
doses do not produce results. The initial dose should not be less than
75 drops of the saturated solution, three times daily, well diluted. This
may be increased 1 drop daily until a maximum of 125 or 150 drops,
three times daily, is reached. If symptoms of iodism intervene, stop
the drug for three or four days and then resume at the same dosage
taken when the drug was discontinued. By this method cases have
taken as high as 150 drops three times a day eventually, with excellent
results and no untoward symptoms.

Surgery is of value only where the tissue involved can be widely excised.
The involved tissue was widely excised and the wound packed with
iodinized gauze and kept open, with the hope of combating the anaerobic
tendency of the parasite. While the surgical treatment no doubt
hastened the cure in most cases, he does not believe it essential except
where softening and abscess formation has taken place. The hard,
inflammatory nodules before the stage of softening has been reached
respond very well to potassium iodide alone as a rule.

Mycetoma. Kirkham1 claims that mycetoma, though knowm and
described by ancient Indian wrriters, has been considered quite rare
and looked upon as essentially a disease of India. It is possible that
it is not as rare as has been supposed, especially in Tropical and serni-
Tropical countries. Probably many cases of mycetoma have been
incorrectly diagnosed elephantiasis, and vice versa. But since we have
learned more of its pathology, this should not occur.

It was first described as a distinct disease in Bret's Surgery in 1840;
but many early writers considered the disease as tuberculous. Its
parasitic nature was' first suggested by Ballingall, in 1855, but it was
not until 1874 that V. Carter found the causal organism. Cultural

1 Surgery, Gynecology and Obstetrics, 1922, No. 6, 34, 686.

190 LEE: SURGERY OF THE EXTREMITIES

methods at this time were crude, and though cases were reported by
Bassini in Italy, in 1888, by Vincent in Algeria, in 1894, and the first
case in Canada by Adami and Kirkpatrick, in 1895, many of these were
regarded as identical with actinomycosis, and it was not until 1906
that Brumpt published a paper showing that actinomycosis was a sepa-
rate and distinct disease from the other varieties of mycetoma which
are caused by separate varieties of fungi.

This disease is distributed throughout the world; but, due to its preva-
lence in India, it has always been regarded more or less as a disease
peculiar to that country. From the number of cases reported from
the different parts of the world, and especially from the Southern
States and Central America, it is very probably that its incidence is
of far greater frequency than is generally supposed; and it is also prob-
able that many cases are incorrectly diagnosed as actinomycosis.

Etiology. Most commonly we have a history of some injury,
sometimes insignificant, which allows the fungus to enter the subcu-
taneous tissues. The disease is most commonly seen in the foot, hence
its name, Madura foot; occasionally it is seen in the hand and rarely
in other regions.

There are two main types of the disease dependent on the color of
the granules which can be expressed from the lesions, namely, white
and black. However, there are many strains of mycetes which have
been classed as causative. The following classification with the date
and name of its discoverer, is perhaps the most complete.

Germs. Species.

f Aspergillus f A. Nidularis (Eidam) 1883.
Ascomycetes \ \ A. Bouffard's (Baumpt) 1906.

Hyphomycetes

Ospora [ O. Tozeuri (Nicolle and Pinoy), 1907.

D. Bo vis (Harz), 1897.
' Discomycetes \ D. Madurse (Vincent) 1894.

[ D. Asteroides (Eppinger) 1890.

Madurella M. Mycetomi (Laveran) 1902.

f I. Mansoni (Brumpt) 1906.
Indiella \ I. Reynieri (Bumpt) 1906.

[ I. Somaliensis (Bumpt) 1906.

With the exception that the discomyces bovis lives in spikelets of
various cereals, little is known of the saprophytic life of these fungi.
It is most common in the barefoot races in the poorer class and in males.

Pathology. Essentially this disease is a hyaline degeneration and
necrosis which attacks all tissues, even at times with giant and epi-
thelioid cells and little attempt on the part of the body at reaction.

Symptomatology. The disease usually begins in the foot following
an injury often insignificant; but sometimes the hand, leg, neck or trunk
may be affected.

Soon after the original wound is healed there is swelling and pain in
the affected part, with a blackish discoloration of the skin, and the
formation of hard lumps, which have a tendency to bleed and show
the formation of sinuses which discharge an oily fluid containing the

7'AT.IA I S

197

characteristic granules. In different parts of the foot new nodules
appear, and the fool swells until it is ultimately converted into a more
or less shapeless mass. The patient frequently complains of a sensation
of foreign body in the foot. In most cases the dorsum of the fool seems
more affected than the plantar aspect. Practically no effect is noticed
upon the system in general. The condition often lasts for years, or
until the part becomes so swollen that the patient is incapacitated for
walking.

Diagnosis. The diagnosis is based on the peculiar swelling of the
foot, with the formation of sinuses which discharge the characteristic
sclerotia. The diagnosis is confirmed by isolating the fungus which can
be grown on ordinary media, and is a facultative aerobe. On glyceri-
nated agar it forms discoid colonies, white in the center and reddish at
the periphery. The mycelian threads and spherical bodies are Gram-
positive, but not acid-fast. It must be differentiated from tuberculous
disease of the foot, actinomycosis and elephantiasis.

Patient's foot before removal. (Kiikman.)

Prognosis. The disease is incurable unless treated surgically.

Treatment. In well-marked cases amputation affords the only
hope of relief. Unlike actinomycosis, potassium iodide, in even large
doses, has no effect (Fig. 5).

Two more cases are reported from Texas by Pagenstecher.1 These
2 cases are characteristic of typical Madura foot, or mycetoma. The
history of the injury is clear in each instance, both patients being
laborers and forced to make their living by manual means, closely
associated with the soil, going barefooted a great deal while at work
(Figs. 0 and 7).

Tetanus. A correspondent of the Journal of the American Medical
Association reports that in the General Hospital, of Madrid, there have
occurred, during the last year, among the operative cases, 9 deaths.

1 Journal of the American Medical Association, 1922, No. 18, vol. 78.

198

LEE: SURGERY OF THE EXTREMITIES

As happens in all such cases when the tetanus germs are transmitted
by the suture material, catgut, the patients were already convalescent
or had been discharged as cured when the tetanic symptoms appeared.

Fig. 6.— Case I. An early stage of rarefactive and productive osteitis confined
to the metatarsal and phalangeal bones of the great toe. The metatarsal bone
of the second toe presents a healed fracture with clear position and slight excess
of callus formation. (Pagenstecher.)

The fact that tetanus occurred in several clinics that had been furnished
catgut at about the same date seems to indicate that the germs were
inside the catgut.

Fig. 7.— Case II. A very late stage of rarefactive and productive osteitis of all the
bones of the foot and the distal end of the tibia and fibula. (Pagenstecher.)

Ashhurst's report on tetanus to the International Surgical Society
is quoted freely because we feel it is the last word on the subject at this
time.

A. Pathogenesis of Tetanus.1 The following propositions may
be accepted as proved. (The evidence on which they are based is

1 Report Ve Congres de la Societe internationale de Chirurgie, Paris, July 19-23,
1920.

TETANUS 199

detailed at length in a monograph by Ashhurst and John.1 All refer-
ences prior to that date may be found there.)

1. The disease is a pure toxemia; the bacilli or their spores may exist
indefinitely in the tissues, and no symptoms will be produced unless
toxins arc formed.

2. In experimental tetanus, when small animals are used, the form
of tetanus ascendens occurs: Here the symptoms of the disease begin
in the inoculated extremity and though other neighboring parts may
become affected subsequently, yet death or recovery usually occurs
before trismus and retraction of the head develop. In the larger animals
and in man, however, the symptoms usually begin first in the muscles
of the neck and jaws, no matter where the point of inoculation; sub-
sequently the muscles of the back and trunk are affected, and finally the
extremities. This form of the disease is known as tetanus descendens.

3. It is a fact that the toxin ascends the peripheral nerves to the
spinal cord.

4. The toxin also enters the general circulation, but only when this
toxin reaches the spinal cord does it produce characteristic tetanic
symptoms.

5. Causes of the Symptoms of Tetanus. The toxin stimulates the
motor cells of the spinal cord, with the result that the muscles con-
trolled by these cells are thrown into tonic spasm; the toxin also ren-
ders the sensory side of the cord extremely susceptible to external
stimulus, so that very insignificant stimuli, such as the slamming of a
door, jarring the patient's bed, a sudden draught of air, etc., will bring
on a clonic convulsion, or at least will greatly intensify, for the moment,
the tonic spasms.

B. Prophylaxis of Tetanus. 1. Certain classes of wou nds, received
in certain surroundings, are more often followed by the development
of tetanus than are ordinary wounds. The Bacillus tetani normally
infests the intestinal tract of horses and cattle (it is found in the intesti-
nal tract of perhaps 5 per cent of mankind) and is deposited with their
dung. Therefore, wounds contaminated with barnyard or highly cul-
tivated garden soil, those produced by dragging in street dust, etc., are
especially liable to bp infected with tetanus bacilli. Gunshot wounds
are liable to contamination not per se, but only as these conditions,
and others, presently to be mentioned, obtain.

Growth of the organisms is favored by anaerobic conditions of the
wound. These are present in any wound in which there is tissue
destruction, which implies cessation of circulation in the devitalized
tissues; the best culture medium for tetanus bacilli is that which con-
tains some dead organic tissue. Contused, lacerated and gunshot
wounds offer ideal conditions for the development of any bacilli present;
and as the bacilli are carried into the wound only by a missile (shell
fragment, fragment of clothing, splinter of wood, rock, etc.) and usually
remain attached to the missile, it follows that wounds with retained
missiles offer the most favorable conditions possible for the develop-
ment of tetanus. Punctured wounds are to be dreaded not because

1 The Rational Treatment of Tetanus, American Journal of the Medical Sciences,
1913, 145, 800; 146, 77.

200 LEE: SURGERY OF THE EXTREMITIES

the vulnerating instrument is retained, which it seldom is, hut because
it was contaminated either (a) even before it pierced the skin, or (6)
because it carried infection from the skin or clothing deeper into the
tissues. Even a superficial brush burn may give rise to tetanus (as in
a ease in Ashhursts' experience) provided the skin or the vulnerat-
ing surface carries tetanus bacilli.

2. Care of the wound is the first step in the prophylaxis of tetanus.
It is Ashhurst's firm belief that efficient care of the wound as soon as
possible after its receipt is by all means the most important feature
in prophylaxis. The report by Clark1 of 100 consecutive cases of
punctured wounds of the foot, produced by nails, without a single bad
result, and the fact that no tetanus antitoxin was employed, indicates
the efficiency of prompt and proper care of the wound, (a) Mechani-
cal cleansing (debridement; extraction of foreign substances; excision
of devitalized tissue) and (6) chemical disinfection (3 per cent alcoholic
solution of iodine) remains, in his opinion, the best agent for this pur-
pose; certainly no cauterizing agent should be used, as this will produce
more dead tissue.

3. Prophylactic use of antitoxin holds second place, but second only
to care of the wound.

There are three factors to be considered in connection with the pro-
phylactic use of the antitoxin: (a) The quantity to be administered;
(6) the site of the injection; and (c) the frequency writh which it should
be administered.

(a) The quantity of the injection: The usual prophylactic dose is
1500 units, U. S. A.

(b) The site of the injection: Usually it is administered subcutane-
ously. It is better, however, to administer it intramuscularly in the
immediate vicinity of the wound in order to flood these tissues with
antitoxin, even before the absorption of toxin has begun. The anti-
toxin so injected finds readier access, it is believed, to the nerves of the
wounded part, and is admitted to the circulation no less rapidly than
when administered by the subcutaneous route.

(q) The frequency of the injection: The first injection should be
given as soon as possible after the receipt of the wound. In military
surgery the first injection almost always can be given some hours before
proper care of the wound can be instituted. This fact is fortunate for
the wounded man because of the frequency w7ith which operation must
be delayed; but in neither military nor civil life does this in any way
impair the doctrine that proper care of the wound is the more important
of the two factors in the prevention of tetanus.

That tetanus may develop after the prophylactic use of antitoxin
cannot be denied; but such cases rarely develop very soon after the
injury, and when they do appear seem to be less severe than most
cases in which no serum has been administered.

These early postserum cases, a class which our French colleagues
have happily named tetanos postserique yrecoce are certainly rarer
than the late postserum cases (tetanos postserique tardif); and it is

1 Boston Medical and Surgical Journal, 1916, 176, 541.

TETANl S 201

undoubtedly due to the nearly universal employmenl of serum pro-
phylactically thai we must attribute the relative frequency, during
the German War, of forms of tetanus rarely encountered in civil life;
I mean the late, the local, the recurrent and the chronic forms of the
disease.

He believes it is incumbent on surgeons to administer a reinject ion
<>f serum to such patients at the time of late operations on pails which
have been wounded, and especially if there is a retained foreign body
or a dense cicatrix rendering all the more likely the continued hut
latent existence of tetanus bacilli or their spores.

C. Treatment of Tetanus. The importance of recognizing the
disease promptly can never be overemphasized. Premonitory symp-
toms must be recognized, and heroic treatment instituted without an
hour's delay.

I. Removal of the source which supplies the toxin. If this source is
known it should be attacked directly: The wound should he widely
opened and mechanically cleansed of foreign bodies, sloughs, etc.
Then it should be treated with antiseptics, and he believes a 3 per cent
alcoholic solution of iodine is the best. The wound should then he
filled loosely with gauze soaked in the iodine solution. Caustic should
be avoided, as favoring the growth of tetanus bacilli by the formation
of sloughs. If the nature of the case demands it for other reasons,
amputation should be done; then the stump should be left open and
treated as the original wound. Probably in many cases it will he well
to follow Porter and Richardson's suggestion (1909) to excise the
related lymph nodes, particularly if they are palpably enlarged.

In the case of a firmly healed wound, on the other hand, it probably
will prove more detrimental to the patient to undertake any formal
operation than to leave in situ deeply placed and apparently well-
encapsulated foreign bodies.

II. To neutralize the toxin the best remedy is antitoxin. But
here, again, as in the question of its prophylactic use, we must inquire
as to the quantity, the site and the frequency of the injection.

1. Quantity of Antitoxin Injected. No matter what the method of
injection, the most important thing is to get the maximum quantity
of antitoxin indicated into the patient's body as soon as possible.
Delay even of a few hours may determine a fatal result: 15,000 units
given within the first three hours after symptoms develop are of more use
than 50,000 units given after six hours, or given in divided doses. It
should be made a rule to administer the total quantity indicated as nearly
as may be all at one time; and after this overwhelming dose of antitoxin
has once been given, to keep the patient's system supplied with anti-
toxin, though in moderate amount, until his recovery seems assured.
Dean1 found the physiologic action of antitoxin in the blood serum
could still be demonstrated as long as twenty, thirty and even thirty
nine days after a single intravenous injection (30,000 units, V. S. A.j.

As will he pointed out below, if the antitoxin is administered subcu-
taneously immense quantities are indicated. For an adult, with the

1 Lancet, 1917, 2, 673.

202 LEE: SURGERY OF THE EXTREMITIES

usual type of case, at least 100, 000 units are required in the first twenty-
four hours; although a less amount may be sufficient for a child or
for a comparatively mild ease, one cannot be sure of the fact, and it is
better to give too much than not enough. Administered intravenously,
a less amount is sufficient, probably 15,000 to 25,000 units should
be administered at first, and if no effect is apparent, or if the good
effect wears off, a similar amount should be given after the lapse of
eighteen to twenty-four hours. If injected intraspinally, from 3000 to
10,000 units should be given, according to the weight of the patient;
this injection need not, as a rule, be repeated in less than eighteen to
twenty-four hours. Even when administered intraspinally, a certain
interval must elapse before the effect of the antitoxin can be apparent.
Intraneural injections, rarely used at present, should be made in as
great amounts as the nerves wifl absorb. He has injected 1500 units
into the sciatic nerve all at one time, on several occasions, and 750
units into each of the anterior crural and obturator nerves. If the
injections are slowly made, all this quantity can be introduced among
the nerve fibers.

2. Site of Injection of Antitoxin. The following sites of injection
deserve consideration: (a) Subcutaneous, (b) intraneural, (c) intra-
venous and (<7) intraspinal.

(«) Subcutaneous injections: Thus administered, the antitoxin is
absorbed by the lymphatics, transported to the veins, passes through
the lungs, and finally is distributed through the arterial system to
all parts of the body. Only an infinitesimal amount ultimately
reaches the motor nerves through which the toxin is being carried to
the spinal cord, while the greatest part is distributed to the viscera
where it is of no use. This method of administration is inferior to the
intravenous in the certainty and rapidity of a neutralizing circulating
toxin, and since overwhelming amounts are required to produce any
effect it is evidently the height of extravagance so to employ it. Should
it be used, at least 100,000 units, U. S. A., should be given in the first
twenty-four hours.

(h) Intraneural injections: Since the more general adoption of
intraspinal injections, the intraneural method has been less used. As
it is a well-ascertained fact that most, possibly all, of the toxin reaches
the spinal cord only by travelling up its nerves, it is theoretically logical
to inject the antitoxin into the nerves in order that, like the toxin, it
may not only block the nerves against further absorption but may
reach the spinal cord by the easiest road. That it will reach the cord
admits of no doubt (Sawamura, 1909). Accordingly, it should be
injected into the nerves at the roots of the limbs.

But as it is manifestly impracticable to expose and inject antitoxin
into all of the nerves throughout the body through which toxin is being
absorbed, and as it is extremely probable, even if not categorically
proved, that antitoxin, when injected intraspinally, acts upon the
toxin already in the nerve roots or spinal cord, it is nearly everywhere
admitted that intraspinal are of more value than intraneural injections;
they are especially valuable when the site of inoculation with tetanus
bacilli is doubtful or unknown. The only methods we possess for

TETANUS 203

reaching all the nerves at once are: (1) Intravenous injections and (2)
intraspinal injections. In no ease, therefore, should we depend on
intraneural inject ions alone. Pratt1 adopted in 1 ease injection (15,000
units) into the vertebra] artery; one artery, he claims, delivers blood to
both sides of the body. The result is not given. He points out that
the circulation from this artery goes chiefly to the medulla and cord,
very little to the brain. Cocaine injected into the common carotid
anesthetized the head and neck without medullary involvement; so
he assumes that the circulation through the circle of Willis is not free
in cither direction.

(c) Intravenous injections: The effects of these were studied experi-
mentally by von Graff (1012) and subsequently by numerous other
investigators. It is the surest and quickest way to neutralize the
circulating toxin, and thus to prevent more of it from reaching the nerves
and spinal cord ; hut it does not enable antitoxin to overtake and neutra-
lize toxin already in the nerves or spinal cord, and it is the latter toxin,
not the circulating toxin, which is doing the damage.

We reviewed last year the work of Teale and Embleton,2 who came
to the conclusion, as the result of their experiments, that antitoxin does
not pass to the central nervous system by way of the bloodvessels,
but that it acts simply by combining with the circulating toxin and thus
prevents it from reaching the central nervous system. It is true that
Dean3 proved that antitoxin may be found in the cerebrospinal fluid in
varying, but never very large, amounts after the intravenous admin-
istration of large amounts; but if it is of any value in the cerebrospinal
fluid it certainly is more rational to insert it directly by lumbar puncture
in concentrated form, than to administer it intravenously.

(d) Intraspinal injections: First used successfully in 1S99 by von
Leyden, who had no doubt that antitoxin was conveyed rapidly to the
medullary cells after its injection into the subdural space of the lumbar
cord. It is a method which is in danger of being neglected, owing to
modern experimental researches. But in spite of the large majority
of experiments, which at first sight tend to show that the intraspinal
administration of antitoxin is of no therapeutic value, because it cannot
be absorbed from the cerebrospinal fluid, there is sufficient clinical
evidence on record to show that antitoxin can be and is absorbed into
the nerve roots or cord directly from the cerebrospinal fluid.

The clinical results of the intraspinal use of antitoxin are these:

RESULTS OF TREATMENT BY ANTITOXIN INTRASPINALLY.

Mortality.
Author. Patients. Recovered. Died. Per cent.

Luckett, 1904 4 4 0 0

Rogers, 1905 7 4 3 43.0

Hotmail. 1907 16 14 2 12.5

Permiii, 1914 28 11 17 60.7

Niooll, 1915 (collected cases) . . 20 16 4 20.0

Gibson, 1916 4 4 0 0

Ashhurst, 1920 14 94 5 35.7

1 New York Medical Journal, 191S, 107, 737.

2 Journal of Pathology and Bacteriology, 1919, 22, 50.

3 Lancet, 1917, 1, 673.

1 One patient died subsequent!}' of pneumonia.

204 LEE: SURGERY OF THE EXTREMITIES

It is true thai in most of these patients antitoxin was given also by
other routes besides the intraspinal (/. e., intravenously and subcutane-
ously), and that other proper methods of treatment were not neglected
(use of sedatives, careful nursing, etc.) for tetanus is a terrible disease
and must be fought with every available weapon. It must also, how-
ever, be borne in mind that the above list includes (at least in the case
of the present writer's statistics) patients to whom antitoxin was given
intraspinally so late that it is scarcely fair to include them in seeking
to determine the value of this avenue of administration. If treatment
is both efficient and early, the mortality from acute tetanus probably
should not exceed 20 per cent.

3. Frequency of the Injections. If the rule already enunciated be fol-
lowed, namely, to administer the total quantity indicated, as near
as may be, all at once, and particularly if the intraspinal (3000 to
15,000 units) and intravenous (20,000 to 30,000 units) methods are
employed, the injections will not need to be repeated very frequently.
Intraspinal injections usually are to be repeated every twenty-four to
thirty-six hours unless improvement commences; the intravenous
injection need not be repeated for several days if improvement com-
mences, but, if the patient continues to get worse, and certainly if a
less amount than 20,000 units has been injected at first, this amount
should be repeated within twenty-four to thirty-six hours.

III. The third indication in the treatment of tetanus is to depress
the functions of the spinal cord. This is equally important with the
effort to eliminate the supply of toxin, and with those to neutralize the
toxin already formed, because, in almost every case, there is a large
amount of toxin which has become impregnably entrenched in the cen-
tral nervous system, particularly in the spinal cord, and none of the
methods of treatment hitherto discussed has any influence over it.
Until its action is exhausted, it continues to stimulate the motor and,
to a less degree, the sensory tracts of the spinal cord, and kills the
patient by exhaustion.

We have at our disposal a number of drugs whose main therapeutic
action is to render the spinal cord less susceptible to stimulus; and
administration of one or more of these remedies forms an integral
part of any rational plan for the treatment of tetanus. The drugs
most often employed are chloral, chloretone and similar products;
the bromides; magnesium sulphate; and, of late years, the persulphate
of sodium. These drugs are to be administered until the therapeutic
effect which is desired has been obtained.

Ordinary doses are not sufficient, but it is quite possible to kill the
patient by an overdose. In 9 patients in my own series of cases the
condition at death was noted: Only 3 patients died in spasm or con-
vulsion, while 6 died in complete relaxation; and in some of these cases
the condition was due to overdoses of the spinal depressants employed.
Especially dangerous, I believe, is magnesium sulphate, which, as
Berard and Lumiere1 express it, is efficient only in a "doses para-

1 Presse medicate, 1918, 26, 409.

TETANUS 205

mortelles." Chloral, in doses of 4 to 10 gm. daily, is the most efficient
and inoffensive of spinal depressants, and Ashhurst habitually employs
it in conjunction with the bromides.

IV. The patient, as well as the disease, must he treated; but it is
perhaps unnecessary here to dwell further upon nursing, feeding and
meeting every untoward symptom as it arises.

During the interval between March 22, 1916, and December 7, 1921,
49 patients with tetanus were admitted to the Los Angeles County
Hospital. During this interval there were 74,393 total admissions,
or 1 admission for tetanus to 1518 admissions for all other causes.
Twenty-six deaths occurred, or a mortality of 53 per cent. Stone1
has made an analysis of the records of these 49 patients and concludes:

1. The most important factor in the treatment of tetanus is its
prevention. It should be the universal rule to give a prophylactic
dose of 1500 units of antitoxin to all patients who have received lacer-
ated or penetrating wounds. If the wound contains necrotic tissue
or a suspected foreign body the dose should be repeated in ten days
and subsequently if operation on the wound is contemplated.

2. Treatment of all extensive lacerated wounds surgically by primary
excision and primary or delayed suture will greatly reduce the incidence
of the disease.

3. The type of infection appears to vary in virulence in different
years. In four different years between 1916 and 1921 the mortality
varied from 14.3 to 71 per cent in a comparable number of patients
each year, with the same general plan of treatment.

4. When symptoms of the disease have appeared the attempt should
be made to saturate the patient with antitoxin before fixation of toxin
has occurred in the nerve cells of the spinal cord. This can best be
accomplished by intraspinal and intravenous injections during the first
three days of treatment.

Prevention of Trismus in Tetanus. Moser2 reports brilliant
success in a case of severe tetanus, in which he combated the tetanic
closure of the jaw muscles by injecting locally an anesthetic as if for
local anesthesia. The tetanus had developed the twenty-second day
day after the man's hand had been crushed in a machine. The second
day of the trismus Moser injected 25 cc of a 0.5 per cent solution of
procaine (novocaine), distributed in both masseters. In a few minutes
the previously tightly locked teeth could be opened and the man could
eat and drink at will, which had been absolutely impossible before.
The effect began to subside in an hour, and by the afternoon the teeth
were clenched as tightly together as before. At 5 p.m. another similar
injection was made, this time above the malar bone, pointing the needle
downward in three different directions. The effect was as prompt and as
decided as after the first, and the patient was able to eat and drink. Two
local injections were required on the four following days. As the effect of
the local anesthetic lasted only for an hour by that time, a change was
made to eucaine. The effect of this was less prompt but it lasted longer;

1 Journal of the American Medical Association, June 24, 1922, No. 25, vol. 78.

2 Abstract, Journal of the American Medical Association, No. 21, vol. 77, p. 690.

206 LEE: SURGERY OF THE EXTREMITIES

one injection in the morning answered for the whole day. By the nine-
teenth day the local anesthetic was no longer needed. He had been
given twenty injections of antiserum, 100 units each, and also morphine,
phenobarbital and camphor at times.

In a second case the local anesthetic conquered the trismus at once
in the same way, but the boy, aged twelve years, could take nothing
but fluids on account of the spasm of the swallowing muscles. He
succumbed the second day to paralysis of respiration.

Intracranial Serotherapy in Tetanus. Frankel1 reports the
recovery of several very grave cases of tetanus after the subdural
injection of antitetanic serum by combined lumbar puncture and
trephine of both hemispheres. In 1 case the incubation period had
been only forty-eight hours, recovery following this treatment. Experi-
mentally, Gottlieb saved rabbits by trephining and injecting the anti-
tetanic serum in the vicinity of the medulla oblongata after an interval
of sixty hours from the time of injection and twenty-four hours after
the onset of the symptoms. Five out of Frankel's 7 grave cases recov-
ered. He further cites 2 of Bocker's and another of Slojonoff.

Surgical Tuberculosis. Our interest in surgical tuberculosis has been
gratified during the last four years by the opportunities afforded as
consultant to the State Tuberculosis Sanatoria of Pennsylvania.

The unfavorable results which generally follow radical surgical
treatment of tuberculosis has been impressed upon us as never before,
and we feel that the attention of surgeons should be called to the
article of Gauvain, which is quoted freely.

The Non-operative Treatment of Surgical Tuberculosis.
After a period of enthusiasm for the surgical treatment of tuberculosis,
involving bones, joints, glands or other accessible structures, there
has come one of reaction in which even the active surgeon, worn by
tragic experience, has withheld surgical interference until forced to
procure mechanical relief of pus under tension, even at the risk of a
possible mixed infection. Gauvain2 confines his remarks to tubercu-
lous disease of the bones, joints and glands and he states that non-
operative treatment in these conditions may be adopted with confi-
dence and reasonable assurance of success, and as he bases his remarks
upon a series numbering between 2000 and 3000 cases between the years
1908 and 1921, they are worthy of critical attention. Gauvain holds
that operative treatment of an active tuberculous lesion is unwarranted
by the pathology of the disease. A tuberculous lesion provokes a reac-
tion, consisting in the formation of a zone of resistance about the
focus of the disease, and it is not reasonable to mechanically break
down this natural tissue resistance. Sir Anthony Bowlby, in 1908,
in an address at Nottingham, reported 900 cases of tuberculosis of the
hip-joint at the Alexandra Hospital, with a mortality of less than 4
per cent, obtained by abstention from major operations in active
tuberculous disease and an aseptic technic in such minor operations
as were indicated. Bowlby at that time laid stress upon the fact

1 Medizinische Klinik, Berlin, March 26, 1922, No. 13, vol. 18.

2 Lancet, May 21, 1921.

SURGICAL TUBERCULOSIS 207

" That tuberculous joint disease is arthritis occurring in a tuberculous
patient, and is not merely a joint affection." This is the keynote of,
and justification for, non-operative treatment of surgical tuberculosis.
It needs the greatest possible emphasis, for even to this day there is
too great a tendency to concentrate unduly on the local lesion and dis-
regard the fact that the patient himself has contracted a general disease,
of which any particular lesion or lesions are merely local manifestations.
Gauvain feels that do striking advance has been made in the operative
treatment of acute tuberculous bone and joint disease unless bone-
grafting of the carious spine be considered as such. This operation,
however, is essentially a conservative measure. Xo attempt is made
to deal with the lesion, but an internal splinting of the bone is secured.
In the majority of cases Gauvain feels that it is an unnecessary opera-
tion if reasonable facilities are available for treating the patient; in
certain cases it lias distinct and considerable dangers, and to his mind
only in a limited number of cases does it present definite advantages.
It is really immobilization of a tuberculous lesion instead of an extir-
pation. The psychology and future well-being of the patient have
been almost totally neglected in the routine treatment of this disease.
The monotony of immobilization, of long-enforced recumbency, of
fixation in unnatural attitudes, cries for alleviation. A state far from
that we see in the normal healthy well-cared-for child, who is happy
when he is given full play for natural healthy mental and physical
activity. In addition to the surgical treatment of the disease, equal
attention, therefore, should be paid the child's education, manual instruc-
tion and amusement, and they should be taught how to amuse and
entertain themselves. He warns against opening tuberculous abscesses
of any of the larger bones or joints, but neither should they be left to
be absorbed. As soon as possible after their formation and as early
in the evolution as the skill of the surgeon permits they should be
aspirated. All patients who have suffered from surgical tuberculosis
should have the continued advantage of occasional skilled supervision.
No special hospital for the treatment of these conditions can be con-
sidered complete unless it possesses an out-patient department where
discharged patients may be periodically examined, advised and assisted.
Not only is medical help required, but advice in the choice of occupa-
tion and assistance in obtaining suitable employment should be at
hand. The mortality percentage in this group of 3000 cases was
2.54 per cent. The mortality of tuberculosis of the spine was 3.39;
of the hip 1.71. Meningitis is the most common terminal cause of death.
Gill1 says this is in accord with his experience at the Wiedner School
for Cripples. Spinal tuberculosis was not only the most common but also
the most fatal form of tuberculosis. Ten of the 13 patients suffering
from spinal tuberculosis, whose death resulted from meningitis, were
under the age of five years. In conclusion, Gauvain says that surgical
tuberculosis is more difficult to treat, is more likely to produce physical
disability and is undoubtedly more fatal in the very young than in
older children.

1 Personal communication.

208 LEE: si RGERY OF THE EXTREMITIES

Factors in Wound Healing. The healing of wounds1 after injury
involves the regeneration of certain tissues. In this process there is
;i resumption of the proliferation of cells. It requires little argument
to indicate the importance of knowing what factors are concerned in
the regeneration processes, for they involve the facility with which
repair may go on in the organism and the speed with which the healing
can be accomplished. Any study of the cicatrization of the wound is,
therefore, something more than a consideration of a mere academic
question. Carrel2 has pointed out that the resumption of cell pro-
liferation in wounded tissues may he attributed, as Welch8 suggested
long ago, to the removal of resistance to growth, in consequence of
the defect resulting from loss of tissues. In other words, lie writes,
"The removal of the products of growth, that is, of a portion of the
tissues, immediately reinaugurates the growth process, jnst as the
removal of the products of a balanced chemical reaction at equilibrium
immediately reinitiates the forward action." This means that regen-
eration, being a direct consequence of the injury, is started by forces
within the organism.

This is not the only hypothesis, however, which will account for
wound repair. It is equally conceivable and logical that external
factors may promote or initiate the cicatrization phenomena. On
this view the cells would he directly stimulated to growth and multi-
plication by forces outside the organism, acting on tissues deprived by
injury of their natural protection. In experimental investigation of
the problem at the Rockefeller Institute for Medical Research, Carrel
has tested the first hypothesis by watching the progress of repair in
wounds protected against all external irritation, lie found that as
long as the wounds were protected by a connect ive-tissue dressing
against mechanical, chemical and bacterial irritation, no evidence of
cicatrization was found. Admitting uncertainty whether cicatriza-
tion could be prevented for any indefinite period, Carrel believes there
is no doubt that the mechanism of regeneration is not set in motion
at thi' usual time, when all external irritations are suppressed. It
appears, he adds, that, under ordinary conditions, cicatrization is not
initiated by an internal factor.

On the other hand, the local application of certain irritants, such
as turpentine, or the presence of bacteria tends to reduce the initial
delay in wound repair the latent period of regeneration. We are
reminded that a small wound will begin to cicatrize sooner if slightly
infected, as practically always happens, than if it were thoroughly
protected by a non-irritating dressing. Perhaps Carrel is correct in
believing that the mechanism of regeneration has become adapted to
the ordinary condition of life where infection or irritation of wounds
is likely to occur. In any event, he is presumably justified in the con-
clusion that regeneration apparently is initiated, not by internal, but by
external factors.

' Editorial, Journal of the American Medical Association, No. 25, vol. 77.
" Journal of Experimental Medicine, November, 1921,34, 125.
Science, L897, 5, 813,

STANDARDIZED RESULTS OF W0\ ND HEALING 209

Aseptic and Antiseptic Surgery. C 'al u>x states that the average
surgeon is so greatly concerned with bacteria as the cause of infection
that he may overlook some <>f the other conditions which predispose to
it. For the development of infection, conditions must fa\ or the gro^ tli
of bacteria; their mere presence will not always be sufficient. The
surgeon who centers his attention on asepsis and its various aspects is
apt to attribute ;i postoperative inflammation to incomplete steriliza-
tion. While a certain small percentage o\' such infections are due
to faulty asepsis, various oilier factors are iA' great importance. The
surgeon is responsible not only for his liability to introduce bacteria,
but for his failure to protect the patient front conditions which make
infection possible.

Such conditions may be either genera] or local.

'The general conditions, which cause a decrease in resistance, are:

1. Fear. A patient who goes to operation with great dread and
anxiety is much more liable to have a poor result than one with tin-
opposite attitude.

2. Starvation. This is not so often a factor as formerly, as today
patients are allowed more nourishment. The diet should not be
restricted, especially in the case of patients at the extremes o^i life.

'.\. Dehydration. Water should be supplied in great quantities not
only up to the time o\' operation, hut even during the surgical treat-
ment and afterward. If it cannot he taken by mouth it should be
given by rectum and subcutaneoiisly.

4. Anesthesia. The anesthetic should be carefully chosen and should
he administered by an expert. Ether is not always the logical anesthetic
simply because it is the most fool-proof.

5. Length of Operation. The time consumed in the operation depletes
the patient's vitality. Especially under prolonged ether or chloroform
anesthesia there is a very unfavorable action upon the tissues, with
lessening o( the alkali reserve and at least some acidosis. Tin- work
should be done with as much speed as is consistent with thoroughness
and correctness of technic. Naturally slow operators, who cannot
acquire speed, should take up some other calling than surgery.

The local conditions favoring infection are:

1. The Preparation of the shin. This should be simple. Irritating
applications should be avoided.

2. Rough Handling of the Tissues-. This is, perhaps, the most import-
ant local factor favoring infection. Roughness in handling, the use
of dull instruments, grasping a mass of tissue to control bleeding, and
heavy, careless dragging with retractors should be avoided as they
cause tissue necrosis which produces a good cult tire medium.

.'!. Faulty Hemostasia. Dry wounds heal quickest and with least
infection.

I. Mass ligatures, which destroy the tissue surrounding a vessel.

Standardized Results of Wound Healing. Gibson2 has made a study
of wound healing in his hospital service, and by systematizing the

1 ( lanadian Medical Association Journal, 1921, 11. 610.

■ Transactions of the American Surgical Association, 1921, 39, 165.

l l

210

LEE: SURGERY OF THE EXTREMITIES

records and adopting a standard of greater accuracy than is usually
obtained, he has been able to study the problems of imperfect wound
healing and methods of correcting them. It is a monthly record and
does not include all of the cases, but a limited group of what might
be called the ideal type, that is, no conditions of possible infection
from the disease itself, as acute appendicitis, salpingitis and drainage
wounds of any kind.

JAN.

II. 17%
III. 3%

FEB.

MAR.

APR.

II. 9%
III. 5%

MAY

II. 4%

JUNE

II. 10%
HI. 3%

SEPT.

II. 5%
HI. 5%

OCT.

II. 5%
HI. 3%

NOV.

DEC.

II. 3% II. 10%

III. 6% HI. 10%

Fig. 8.— Results of wound healing— 1920. Class I (white). Ideal wound heal-
ing. Class II (shaded). Slight mishaps. No detriment to wound healing. Class
III (black). All infections. (Gibson.)

Manner of Tabulating the Results. The material is divided into
three groups: Grade 1 represents absolutely irreproachable wound
healing. Grade 2 represents small disturbances of wound healing,
such as small hematoma or trivial infection, but none of these accidents
delaying the healing beyond the normal period. Grade 3 represents
all other cases, that is, all infections.

STANDARDIZED RESULTS OF WOUND HEALING 211

He feels that it is particularly important to differentiate between
hematoma, classified under Grade 2, and infections of Grade 3, as the
Grade 2 mishaps, are more apt to represent individual errors, while
Grade 3 may well be laid to a faulty system.

Manner of Grading. They are made by Gibson personally during
weekly rounds. If wounds are definitely healed, say at the end
of seven or eight days, the grade giveD is usually final. These notes
are all given in the presence of the entire staff, and if any possible dis-
sension exists the consensus of opinion rules. At the end of the month
the results are -tabulated as indicated in Figs. 8 and 9. At the monthly
conference a discussion of the causes of disturbances of wound healing
takes place.

JAN.

FEB.

MAR.

APR.

II. 13%
III. 4%

MAY

JUNE

II. 3%

Hi. 8%

Fig. 9.— Results of wound healing— 1921. (Gibson.)

II. 3%
III. 8%

Of the 437 cases classified as to wound healing, there were 39, or 9
per cent, with disturbances. Grade 2—25, or 6 per cent; Grade 3—
14, or 3 per cent. His object in publishing his report is to emphasize
the great importance in a hospital service of systematically earning
out such an investigation. He feels that, from their experience, it
has been a stimulus to every operator and has been most helpful to
both the patient and the surgeon.

As the German literature is becoming accessible it is possible to
obtain reports of their war surgery.

On the first day of the German Surgical Congress, Berlin, May 10,
1922, Lexer1 spoke upon general surgical infection, and differ-

Berlin correspondent, Journal of the American Medical Association.

212 LEE: SURGERY OF THE EXTREMITIES

entiated two principal groups: Bacterial infection and general toxic
infection. These two forms of infection overlap, to a certain extent,
but the distinction is a practical one. Then there are mixed types of
the first and second groups, which were in the past referred to as septi-
co-pyemia. Fever is not necessarily the expression of a general infec-
tion, but may be of a toxic nature (resorption fever). Changes in the
clinical picture will establish the diagnosis. Demonstration of bac-
teria in the blood furnishes the final proof; the absence of bacteria
points to the toxic type. If there are bacteria in the blood and the
number is increasing, it is of little importance whether the augmenta-
tion takes place in the blood or whether new bacteria are being con-
tinually thrown into the blood stream from an outside focus. Lexer
thinks that the active increase of bacteria in the blood is an established
fact. It is worthy of note that the severest acute types of bacterial
general infection may persist for some time without developing metas-
tases. However, metastatic types are often less dangerous. There is
a certain relationship between metastases and resorption fever— the
resorption of bacteria.

General toxic infection may be divided into infection from animal
toxins, infection from bacterial toxins and infection from so-called
tissue toxins. An example of the first group is snake venom; of the
second, tetanus, and of the third, the toxins associated with burns. A
separation of bacterial toxins and tissue toxins is important. There
are also transitional forms. Not all pathologic manifestations are
traceable to bacterial toxins.

In this connection, a number of questions arise that still await solu-
tion; for example, whether the tissue toxins alone play an important
role and to what extent they break down the defense measure of the
organism. They often act after the manner of foreign protein, produc-
ing fatigue phenomena and similar manifestations. Injection of tissue
toxins into animals causes local signs of inflammation. These phe-
nomena often take on the form of anaphylactic symptoms. Possibly
we have here an explanation of the vasotonic effect brought about by
the parenteral administration of proteins. Also, the action of shock
may possibly often be explained by intoxication through decomposition
products (toxemia traumatica). In any event, a separation of the
tissue and bacterial toxins must always be sought.

According to the statements of Eden, with regard to inflamma-
tory processes and wound infection from the standpoint of physical
chemistry, the organism endeavors to counteract disturbances by
sending to the part affected an increased supply of blood. Thus,
hyperemia may bring about an adjustment in the inflamed area in
which the physico-chemical disturbances (for instance, in the form of
an increased hydrogen-ion concentration and an augmented osmotic
pressure) find expression. Therefore, we should not, in such cases,
use substances intended to combat hyperemia — not even though they
be bactericidal. The preservation of nerve conduction is important
in connection with hyperemia, as is shown in roentgenograms depicting
the healing of artificial fractures with and without severance of the

SURGICAL STERILIZATIOA OF WOUNDS 213

sciatic nerve. II the nerve is not severed there is hyperemia, and
callus appears l>.\ the end of two weeks; otherwise, not until a much
later period. We should employ substances that attract leukocytes
instead of repelling them, as we need the leukocytes to heal the wounds.
In this connection, the influence of electrolytes, through the rearrange-
ment of ions, and also the conditions of osmotic pressure play an import-
ant part. In an acutely inflamed area, in the presence of marked
hypertonia, edemas and impeded influx of blood, we must not employ
such substances as increase the pressure of the tissue proteins due to
the absorption of moisture, which accentuate metabolism, or bar the
road for the elimination of injurious metabolism products, even though
such a substance may exert a bactericidal action; otherwise, an incision
will be required to relieve the tension and save the tissues.

In the case of chronic inflammations, on the other hand, an accentu-
ation of the inflammatory processes will bring about an adjustment
of the disturbances and lead to a cure. Physio-chemical processes also
exert a decisive influence in the destruction of bacteria and in the
formation of toxins. Only with the possession of an exact knowledge
of these processes and their bearing on the healing process in wounds
will it be possible to discover a clinically useful disinfectant; and it
must be borne in mind that the processes to be noted in a fresh wound
are different from those in an inflamed wound, and that these, in turn,
differ from the reactions in the test-tube.

Surgical Sterilization of Wounds. Butler1 restates the theory of
surgical sterilization, or debridement, in recent, grossly contaminated
wounds, which we have reviewed at length during the last three years.

Debridement is not a simple procedure. It requires time and, in
the very great majority of cases, general anesthesia. It demands also
more than average surgical ability. The aseptic precautions require
a degree of teamwork which can be obtained only by long practice.
Early in his experience the surgeon should delay closure of the wound
for a few days following debridement, but as his skill increases he
may add immediate primary suture.

Military surgery established the fact that it is safer not to close
wounds in which great numbers of streptococci or fecal anaerobes are
found. In civil hospitals, unless it is known that the patient is willing
to remain in the institution for^ from seven to ten days, immediate
primary suture should not be attempted. Moreover, immediate pri-
mary suture in cases of metabolic disturbances, vascular changes,
chronic alcoholism, or demonstrable syphilis does not promise great
success. Delayed primary suture or antiseptic treatment is a wiser
course.

An infected wound requires more skilled attention than a clean
wound, and in a contaminated wound the prevention of infection is a
still more difficult problem. Given proper technic, sound judgment,
and increasing skill in debridement, a successful result should be obtained
in 90 per cent of the cases.

1 American Medicine, 1921, n. s., 16, 20."..

214 LEE: SURGERY OF THE EXTREMITIES

Treatment of Acute Suppuration. Saner1 states that the constant
use of the word drainage is probably responsible for the general accept-
ance of the principle that drainage is the chief factor in the treatment
of suppuration. Saner suggests that this term drainage should be
eliminated and replaced by "relief of tension," which does not suggest
evacuation by means of tubes or wicks, but implies an opening, along
which the products of inflammation may escape. The second great
principle, after the relief of tension, is rest or immobilization. Only
by completely immobilizing an inflamed part are the natural tissue
forces given a chance to form barriers against the spread of inflamma-
tion and thus localize the process. This principle not only applies to
soft tissues, but is demonstrated to the maximum degree in bone.
Tension here is at the maximum because of the unyielding character
of the bony wall surrounding the medullary cavity. In joints, aspi-
ration may, in many instances, give sufficient relief of tension.

Experimental Research in Wound Drainage with Dry and Moist Dressings.
Schoenbauer and Deniel2 report an experimental investigation of the
influence of drainage by rubber tube, iodoform gauze strips, or a wick,
upon the entrance of pathogenic bacteria into simple wounds or the
larger hematomata when dry and wet dressings are used.

They conclude that rubber drain favors the entrance of bacteria
present on the skin, that iodoform gauze does the same, but in less
degree, and wick drainage opposes bacterial advance. In cases of
gauze and wick drainage, moist dressings appear to retard the entrance
of bacteria.

Physiologic and Therapeutic Action of Light. Universal experience has
demonstrated the benefits of heliotherapy in whatever primitive forms
it has been applied, and probably it is the oldest of all forms of therapy.
More exact modern methods have served to support the experience of
the ancients, and the recent experimental study3 of rickets has fur-
nished a most remarkable instance of the definite, if inexplicable, etio-
logic relation and therapeutic effect of light. As stated by Hess,4 in
his review of this topic, the experimental production of rickets by
defective diets may be determined or prevented by sunlight or artificial
light of sufficient intensity and proper quality, and human rickets may
be improved or cured by the same agency. The frequency of rickets
in negroes and the dark-skinned white races occupying northern cities
evidently depends partly on defective nutrition and partly on the
shutting-out of the sunlight by the pigment intended to protect them
from excessive doses of light in their native habitats. Heliotherapy in
tuberculosis has also taken a definite place in therapeutics, while the
therapeutic effects of radiant energy in other forms is, of course, one
of the most rapidly growing aspects of medicine, often leaping far
ahead of any safe experimental foundation.

1 Lancet, London, October 29, 1921, 2, 891.
* Arch. f. klin. Chir., 1921, 116, 731.

3 Editorial, Journal of the American Medical Association, May 6, 1922.

4 New Aspects of the Rickets Problem, Journal of the American Medical Asso-
ciation, April 22, 1922, 78, 1177.

PHYSIOLOGIC AND THERAPEUTIC ACTION OF LIGHT 215

A thorough review of the subject of the physiologic action of light,
by Janel II. ('lark,1 is, therefore, most timely. We learn that despite
the long history of heliotherapy, the first systematic effort to study
the biologic effects of light, and its therapeutic uses, was made by
Finsen, when he founded his light institute in Copenhagen in L896.
Most valuable work, both theoretical and practical, has been done
there since, with special success on the therapeutic side in the treat-
ment of lupus, hut the fundamental problem of the mode of action of
light on the living cell remains unsolved. Although there is a universal
conviction that sunlight is healthful, it is certain that human beings
and animals can live a long time in darkness without any noticeably
bad results. Blessing, who acted as physician to Xansen during his
expedition in the Fram, published a report showing that members of
the party exhibited no evidence of anemia during the trip. More
recently, Grober and Sempell examined horses that had worked for
years in coal mines, and found no anemia in any case in which a satis-
factory nutritive condition existed. But, though the physiologic
effect of sunlight seems at first sight indefinite and of dubious import-
ance, the action of far ultraviolet light on normal tissue and the action
of near ultraviolet and visible light under certain pathologic conditions,
has been investigated enough to show that there are well-defined
effects due to light, closely related to the physiologic results of exposure
to radium and the roentgen rays.

Recent contributions have come chiefly through study of the bio-
logic effects of light in relation to the wave length of the rays con-
cerned. In general, the shorter the ivave length the greater the physiologic
effect. The spectrum of sunlight reaches only to 290 microns in the
ultraviolet, and light greater than 300 microns being our normal envi-
ronment, it is obvious that any organism ordinarily exposed to this light
and easily injured by it would have perished long since. Light less
than 300 microns is an unnatural environment, and produces in all
living cells strong and often very harmful reactions. Since the effect
of light is probably due to the photochemical reactions produced when
light energy is absorbed, it is not surprising to find that the various
constituents of protoplasm begin to absorb light strongly in the neigh-
borhood of 300 microns. We find that bacteria begin to be killed
quickly by wave lengths of 296 microns or below, and hence sunlight
contains a few rays short enough to affect bacteria except on prolonged
exposure, or at a higher temperature which augments the effect of light.

We do not know7 the exact nature of the photochemical reactions
produced in protoplasm by ultraviolet light, although various clues
have been suggested. Bovie finds that paramecia exposed to a sub-
lethal dose of ultraviolet light are so sensitized to heat that they cannot
stand, even for sixty seconds, a temperature which is the optimum
for the controls. He concludes that death from ultraviolet light is
due to heat coagulation following sensitization by radiation. Others
have found that the effect of ultraviolet light on protein solutions is
to make them less soluble, as indicated by their easier precipitation.

1 The Physiologic Action of Light, Physiology Review, April, 1922, 2, 277.

216 LEE. SURGERY OF THE EXTREMITIES

Snow blindness depends on the reflection of ultraviolet rays from
large areas of water and snow fields, these short rays being absorbed
by the cornea and conjunctiva with resulting injury to their protein
constituents. Any artificial illuminants, such as the quartz mercury
arc and bare metallic arcs, which emit a large amount of radiation of
a wave length less than 295 microns, are known to be extremely inju-
rious to the eyes. These short rays are^ the ones that stimulate the
formation of lymphocytes in man and animals, which may be a factor
in the heliotherapy of tuberculosis. Light exerts some influence on
body metabolism, as is shown by a number of results indicating a change
in the amount of carbon dioxide expired, a change in rate and depth
of respiration, and an increased rate of growth in the light compared
to the dark. However, the effects are not as great as might be expected,
presumable because the chemically active rays cannot penetrate deeply.

A remarkable phenomenon produced by light is that of photody-
namic sensitization, in which, through the action of various chemicals,
the tissues are sensitized, just as one sensitizes a photographic plate,
so that they are affected by visible light rays. Among the substances
producing this effect is hematoporphyrin, derived from hemoglobin,
which so sensitizes animals that sunlight is promptly fatal. Possibly
the skin reactions of pellagrins to exposure to light depend on such
sensitization.

As yet, relatively little investigation has been made as to how helio-
therapy produces its effects in tuberculosis and rickets. In the latter,
roentgenoscopy discloses that under the influence of sunlight the recal-
cification of bones proceeds at an accelerated rate, and chemistry
reveals an increase in the inorganic phosphorus of the blood. Cod-
liver oil does much the same thing, and it is difficult to understand
how sunlight and the oil can produce similar effects.

The physicists and biochemists will have to determine the explanation
of the effects produced by the sun's rays; for the clinician it is import-
ant to realize that we are only at the threshold of the subject of the
physics and physiology of light and that, as these advance, new and
probably unexpected therapeutic advances will also come.

Heliotherapy has been gradually introduced at the Mount Alto Sana-
torium in Pennsylvania during the last four years, and it is the opinion
of the entire staff that tuberculous lesions of the bones and joints have
been definitely benefited.

Torraca,1 experimenting with guinea-pigs at the Institute "Angelo
Mosso," on Monte Roa, at an altitude of 9000 feet, made comparison
of the results of three kinds of treatment: (1) Uncovered wounds in
the shade; (2) uncovered wounds in the sun; (3) bandaged wounds.
At the end of twelve days those in Class I had contracted one-third ;
in Class II, one-half; in Class III, three-quarters. The more rapid
healing of bandaged wounds is attributed to the protection from the
cold air of the high altitude. The ultraviolet rays abounding in clear
mountain air probably have a stimulating effect on healing, as was

1 Arch. ital. di chir., Bologna, June, 1921, 3, 401.

PHYSIOLOGIC AND THERAPEUTIC ACTIOh OF LIGHT 217

shown, not only by the greater rapidity of chemical reactions, but also
by the method of liberation of iodine from potassium iodide. The
solar action may act directly by influence on cellular processes, to
which is due the reparation of lost substance; or indirectly, by elimina-
tion of any conditions that might disturb healing. Torraca found that
within a few hours wounds exposed to direct sunlight show greater
contraction than those in the shade; and that solar rays exercise a
biologic action favorable to cicatrization of aseptic wounds.

Ahlswede1 states that, owing to the lack of sufficient sunlight in
northern Europe, it was necessary to search for adequate substitutes
and these were found chiefly in the Finsen lain]) and the mercury vapor
lain]). Hensen and Johansen believe the Finsen light approaches
nearest to the sunlight in its effect because it contains the same pro-
portion of short wave rays and long wave penetrating rays as sunlight.
The mercury vapor lamps, on the other hand, differ from sunlight in
that they contain larger groups of violet and ultraviolet rays, as well
as a larger proportion of short-waved and less penetrating rays than
are found in sunlight or in the Finsen light. The ultraviolet spectrum
of the mercury vapor lamps contains such short-waved rays (from
292.5 to 218.6 r.), which do not exist in either sunlight or the Finsen
light. To use the mercury vapor spectrum they must be placed at
a distance of one yard, the short waves being absorbed by the air at
this distance. When a stimulating effect is desired, as in the treatment
of wounds, the short-waved rays may prove useful.

The effect of light on an unprotected skin showrs the following visible
degrees of intensity:

Erythema due to heat.
Inflammation due to light.
Pigmentation.

The erythema is seen immediately after exposure of the skin. It
appears as a hyperemia, which rarely lasts more than an hour and
then disappears. Mercury vapor lamps do not cause this reaction as
heat rays and are not contained in their spectrum.

The inflammation of the skin produced by light is seen in from
five to ten hours after the exposure. The degree of the inflammation
depends upon the length of the exposure and the intensity of the light.

As to the pigmentation, this is generally seen in from twTo to five days.
It is really a defensive action of the body against the light. The
erythema gradually turns darker, and becomes almost brown. The
skin begins to peel off. The skin gets used to the light and its sensi-
bility decreases to such a degree that inflammation of the skin does
not occur, even after prolonged and intense exposure to the light rays.
This, however, applies only to the Finsen light and sunlight. Mercury-
vapor rays always cause erythema and the skin cannot become immune
to their influence. The effect of light is not confined to the surface,
but is general. Hansen has shown that the Finsen light effects an
increase in hemoglobin and in the red blood cells. Hertel demon-

1 Urologic and Cutaneous Review, September, 1921.

218 LEE: SURGERY OF THE EXTREMITIES

strated that, under the influence of light, the hemoglobin passes its
oxygen to the tissues more rapidly.

Effects of Hot and Cold Applications to the Surface of the Body. For
generations application of heat and cold have been made for the pur-
pose of more or less influencing the deeply seated organs, but the reasons
for and against such procedures have been based purely upon clinical
observation and little real scientific research has been directed toward
determining the actual effects which are produced. MacLeod and
Taylor1 report investigations which they carried on in the University
of Toronto. In a previous report they showed that the application of
heat to the surface of the thigh in the rabbit caused an immediate rise
in temperature, which spread laterally for about 20 mm. and pene-
trated into the muscles for about the same distance, when the applied
heat was approximately 10° C. greater than the natural heat of the
skin. On the surface of the abdomen, when a temperature difference
of 15° was applied to an area about one-quarter of the abdominal
surface, the temperature changes are induced to a depth of 75 mm.,
and the lateral spread was 20 mm. They seemed to prove that this
rise in temperature was mainly dependent upon the induction of heat
through the tissues. This later research was concerned with cold.
When cold was applied, which was 20° C. below the normal temperature
of the tissues, a fall of 14 or 15° C. immediately under the applicator
and the lateral variation in temperature extended to about 20 to 25
mm., which corresponds to that obtained with heat. The drop in
temperature was very sharp at first, and there was a quick return to
normal when the applicator was removed. They were unable to find
that the application of heat or cold to the surface of the body over-
lying the liver and kidneys resulted in any significant change in the
temperature of these organs. Their most significant and important
observation was the influence of heat and cold applied to the head
upon the temperature of the brain. They found that cold definitely
influenced the temperature of this organ, cooling it to a depth of 14
mm. when the cold applied varied from 7 to 10° C. below the normal
temperature of the surface. When still lower temperatures were used,
the fall of the brain temperature became very marked indeed, falling
as much as 3 to 4° C. to a depth of about 14 mm., when the applied
temperature was about 25° C. below that of the body. It is interesting
to note that the application of heat to the head did not produce as
great a temperature change in the brain substance as did the application
of cold. These facts have considerable importance from the thera-
peutic standpoint. It has been believed in the past that the applica-
tion of cold to the head in the course of fevers at least acted as a com-
forting agent by producing a pleasant sensation, or by so modifying
the circulation in the brain, through the nervous system, this effect
was produced. These investigations of MacLeod and Taylor indicate
that the temperature of the brain is directly influenced by external
applications of heat and cold, and particularly by cold.

1 Lancet, London, July 9, 1921, 2, 70.

SHOCK 219

Mechanism of Lowered Resistance following Exposure to Lowered Tem-
perature. Bibb1 conducted a study for the purpose of ascertaining,

if possible, the functional and structural changes which follow chilling
of the body surface, and which lead directly or indirectly to disease.
The belief has long been held by clinicians and investigators that when
the surface of the body is chilled, certain of the internal organs, par-
ticularly the respiratory organs,. become more susceptible to bacterial
invasion. Other authors, after careful investigation, have reached the
conclusion that exposure to lowered temperature, of and by itself,
may be a complete cause of disease without the intermediation of
bacteria. It was, therefore, planned to subject an animal to sudden
and severe lowered temperature and to take note of alterations of func-
tion or structure, with special reference to the possibility of increased
susceptibility to zymotic disease.

The changes provoked in rabbits by the ice-bath are as follows:

Multiple minute hemorrhages in the lungs.

Multiple minute hemorrhages in the stomach.

Changes in blood content of tracheal mucosa.

Contraction, followed by congestion, of the spleen.

Pallor, followed by redness, of the skin.

Albuminuria.

Leukopenia, followed by leukocytosis, in the peripheral blood.

The first five of these changes are apparently caused by vasomotor

variation. The remaining two are closely related to vasomotor function.

The following hypothesis is offered in explanation of the increased

susceptibility to bacterial invasion brought about by chilling the body

surface.

(a) That vasomotor tone and organ function are maintained by the
successive functionation of different shifts or relays of cells, each having
its own threshold of susceptibility to stimulation and rehearsing its
stereotyped function according to the laws of fatigue and its own
individual needs.

(b) That vasomotor changes exert a provocative or stimulating effect
on tissue cells, causing an increased discharge of function.

(c) That early, though fully developed, inflammation, with all the
classic symptoms, is to be explained as excessive liberation of cell
function, and this may lead later to exhaustion, incoordination and
the consequences of these.

(d) That the cell tends to summate the various similar and dissimilar
stimuli playing upon it at each given instant and react to its environ-
ment as a whole.

(e) That the vasomotor changes set up by lowered temperature can
be summated with the stimulation from relatively harmless bacteria,
so as to bring on an excessive liberation of function constituting an
inflammation of the affected part.

Shock. Two interesting editorials have appeared in the Journal of
the American Medical Association during the year and they practically
summarize the subject up to the present time.

1 American Journal of Medical Sciences, 1921, 162, 258.

220 LEE: SURGERY OF THE EXTREMITIES

Exhaustion Produced by Extreme Emotion.1 That the emotions
play upon our physiologic reaction is a thesis that scarcely needs to
be defended. The digestive secretions, for example, are influenced
by psychic states in striking ways to which the Russian physiologist,
Pawlow, has forcefully directed attention. The idea of food may become
a stimulus for the flow of saliva or even gastric juice, whereas such
emotional states as anger, fear and sorrow may succeed in inhibiting
the normal secretion. Strong emotions are attended by more or less
well-defined changes in the circulation which, in turn, cannot remain
without some influence on the tissues reached by the altered blood
supply. It is by no means easy, however, to define the part the emo-
tions per se, and exertion that accompanies them, respectively, play
in producing the consequent exhaustion. Recently, Crile2 has sum-
marized the results of his extended experiments in this field, and boldly
maintains that emotion causes a more rapid exhaustion than is caused
by exertion or by trauma, except extensive mangling of tissue, or by
any toxic stimulus except the perforation of the viscera. In a recent
issue3 the probable involvement of toxemia in some of the most
severe forms of shock was pointed out. As intoxication of a similar
sort is less likely in cases of emotional exhaustion, unless the toxic
substances are identified as products of fatigue, it may be that
shock and "nervous exhaustion" must be more clearly differentiated
in the near future. Because prostration is the end-result in either
case, it by no means follows that precisely the same causes are at work.

Shock as a Result of Toxemia. During the World War the sub-
ject of shock early assumed a place of unusual prominence in connec-
tion with the surgical problems presented by the injured. The topic
was in no sense a new one, for the genesis of surgical shock had already
been debated many times and had given rise in a variety of more or
less conflicting and inconclusive speculations in medical literature.
These earlier hypotheses, as well as more recent ones, were earnestly
discussed by physiologists and surgeons in the eventful days of supreme
military activity, in the hope of discovering some tenable solution of
the cause of shock and of providing some rational procedure for the
relief of its threatening symptoms. The history of these efforts has
repeatedly been discussed4 particularly at the time when the need of
more knowledge was greatest.

Cannon has recently summarized the best-known features of wound
shock as characterized by a low venous pressure; a low or falling arterial
pressure; a rapid, thready pulse; a diminished blood volume; a normal
or increased erythrocyte count and hemoglobin percentage in peripheral
blood; a leukocytosis; an increased blood-nitrogen; a reduced blood-alkali
content, a lowered metabolism; a subnormal temperature; a cold skin,
moist with sweat; a pallid, grayish or slightly cyanotic appearance;
thirst; rapid respiration; often vomiting and restlessness; anxiety,

1 Editorial, Journal of the American Medical Association, March 4, 1921.

2 Archives of Surgery, July, 1921, 3, 116; ibid., January, 1922, 4, 130.

3 Editorial, Journal of the American Medical Association, February 25, 1922,
78, 585.

4 Ibid., February 25, 1922.

SHOCK 22]

changing to mental dulness and lessened sensitivity. Many of these
features, lie adds, may appear at once, or as soon after the reception of
the wound as the observations can be made; or they may develop only
after the lapse of several hours. At one time it was urged that the wide-
spread effect in the organism induced by severe trauma might be due to
nervous impulses. Numerous investigations, however, have made such
a theory untenable. It matters little for the outcome of the trauma
whether the injured parts are denervated or not; in truth, there is no
clearly demonstrable essential relation between the production of
shock and an excessive stimulation of the central nervous system.
Equally true is the now recognized fact that the low blood-pressure
initiated by severe injury is not primarily due to a loss of vasomotor
tone or any comparable sort of exhaustion. As Cannon has con-
vincingly pointed out anew, if the blood-pressure resulting from local
trauma is not due to loss of blood into the injured region, or to reflex
vasodilation, or to depression or exhaustion of the vasoconstrictor
center, or to fat emboli, or to acapnia, the connection between the
local damage and the general bodily state may reasonably be looked
for in the remaining great connecting system— the circulation.

In harmony with this conclusion, there has arisen a theory of a
toxemic cause of wound shock, based on evidence for the existence of
a toxic factor liberated in the injured tissues.

Experimental and Anatomo-pathologic Research. Cornioley and Kot-
zareff's1 experiments regarding traumatic toxemia wrere carried out on
rabbits and guinea-pigs. The results of seventeen experiments, which
coincided in general with wdiat is already known on the subject, are
summarized as follows:

1. While a ligature remained in place above the crushing lesions,
the general phenomena of traumatic toxemia remained slight or were
absent.

2. When the ligature was suddenly removed after a period of a few
hours, during which no general morbid phenomena were noted, the
animal died very soon as the result of rapid absorption.

3. Amputation done immediately after a crushing injury and above
the lesion saved the animal's life, and such animals did not at any
time show symptoms of shock.

4. Intravenous or intraperitoneal injection of the sterilized and
filtered product of muscle crushing caused death, and the same physio-
logic phenomena and macroscopic and microscopic lesions as those
noted in animals with a crushing injury.

5. If a crushing injury wras left exposed, the animal did not at any
time show toxic phenomena, as the autolytic products were allowed to
flowr away. The fact that shock remained absent, although the open
and non-dressed wound could easily have become infected, seems to
prove that traumatic toxemia is not due to bacteria.

Striking analogies between the physiologic effects of certain occa-
sional tissue components and the phenomena of surgical shock have

1 Rev. de chir., Paris, 1921, 40, 1.

222 LEE: SURGERY OF THE EXTREMITIES

been presented by Dale and his associates in England. Poisonous
protein derivatives, products of partial digestion, of bacterial action
and tissue manipulation readily produce fall of blood-pressure attended
with a series of changes, in which "dilatation of the capillaries and
pooling of blood within them, poisoning of their endothelial walls so
that they are abnormally permeable, escape of plasma through these
walls into the tissue spaces, and consequent concentration of the cor-
puscles are the main features." Championing the importance of these
features characteristic also of traumatic shock, Cannon has presented
a convincing review of clinical, as well as purely experimental, evidence
for traumatic toxemia, citing in particular the notable contributions
of the French surgeon Quenu. They show, among other interesting
observations, that anything which delays or checks absorption from
the injured region delays the development of shock; but if there is
a sudden removal of the check serious results follow.

If shock is actually the outcome of intoxication, presumably by pro-
tein derivatives set free from areas of tissue destruction, some of the
manifestations of severe burns become more easy of interpretation.
As Cannon concludes, in harmony with other experts in this field, the
present conception seems to be that not only the shock following burns,
but also the delayed shock consequent on severe trauma, are properly
placed in the same category with other forms of general depression of
bodily functions and defective circulation due to the setting free of
toxic material.

In the development of our conception of the effects of extensive burns
there has been an evolution of ideas similar to that which has occurred
with regard to traumatic shock. Sonnenberg1 and Virch2 attributed
death from burns to a reflex depression of the vasomotor tone. Modern
studies— Becker Schnitz ("Klinische und chemische Beitrage zur
Pathologie der Verbrennung")3 and Weiskotten (" Histopathology of
Superficial Burns")4— have shown that there is, as in shock, a great
increase in the number of erythrocytes, i. e., concentration of the blood
and an enormous mobilization of leukocytes. The suggestion of
recent writers— Bardeen,5 Eyff,6 Pfeiffer7 and Vogt8— is that, here too,
death, when delayed, is the outcome of an intoxication, probably by
a protein derivative set free from the area of tissue destruction. The
present conception seems to be that not only the shock following burns,
but the delayed shock consequent on the severe trauma, is properly
placed in the same category with other forms of general depression of
bodily functions and defective circulation due to the setting free of
toxic material in the body.

This similarity of the shock, which follows burns during the first

1 Deutsch. Ztschr. f. Chir., 1877, 9, 138.

2 Arch. f. path. Anat., 1880, 80, 381.

3 Mitt. a. d. Grenzgeb. d. Med. u. Chir., 1919, 31, 416.

4 Journal of the American Medical Association, January 25, 1919, 72, 259.

5 Bulletin of the Johns Hopkins Hospital, 1898, 9, 137.

6 Centralbl. f. d. Grenzgeb. d Med. u. Chir., 1901, 4, 128.

7 Virchows Arch. f. path. Anat., 1905, 180, 367.

8 Ztschr. exper. Path. u. Pharm., 1912, 11, 191.

'(/

OXYGEN NEED DURING ANESTHESIA 223

twelve to twenty-four hours, to the phenomena seen during the same
period after traumatic wounds of war was noted by Lee and Furness,
and they developed a surgical treatment of burns comparable to the
surgical treatment of traumatic wounds now universally accepted.
This was first published in the Therapeutic Gazette in 1918, and reviewed
in Progressive Medicine in 1919.

Anesthetic Properties of Pure Ether. At least twice within the last few
years it has been reported that pure ethyl ether is not an anesthetic,
and that the physiologic action ordinarily attributed to this compound
is due to impurities contained in the commercial material. According
to Cotton,1 carbon dioxide may be the active agent in some ethers; but
this investigator reported that he had obtained the best results by the
use of ether containing ethylene, and possibly another gas of unrecog-
nized nature. According to Wallis and Hewer,2 ketones are the most
important impurities, though they state that the anesthetic action of
ether is enhanced by treating it with carbon dioxide and ethylene. The
lack of chemical details in the papers of Cotton and of Wallis and
Hewer is unsatisfactory. The foregoing statements appeared to
warrant further investigation, and Stehle3 found that pure ether, made
by a clean-cut chemical reaction, which excludes almost completely
any contamination with substances which have been claimed to be the
real anesthetic agents of ordinary ether, possesses to the highest degree
the anesthetic properties which have usually been attributed to it.

Oxygen Need during Anesthesia. Jones and McPeek4 have been
experimenting on animals to determine the relative viability of the
respiratory and cardiac systems under anesthesia, especially nitrous
oxide oxygen. Nitrous oxide, although it supports combustion out-
side the body, acts like any other indifferent gas while in the tissues.
The effect upon the central nervous system is due to the exclusion of
oxygen, because if it were an indifferent gas no effects could be obtained
with a 4 to 1 mixture, since atmospheric air is 4 parts nitrogen to 1
part oxygen. The effect of the gas on the body begins as a suboxy-
genating process in the pulmonary circulation where, owing to the
supply of oxygen being cut off, the venous blood of the artery passes
unchanged into the minute radicals of the pulmonary veins, causing
more or less stagnation, resulting in a general anoxemia that may
quickly develop into asphyxia unless the gases are properly mixed.
Toxic doses of nitrous oxide cause death by respiratory paralysis.
Experimentally, this was shown to be the case; one heart continued to
beat for over five minutes after the respirations had ceased.

To determine the ratio between the hemoglobin index and the
oxygen need, guinea-pigs were confined in bell-jars and fed varying
amounts of the gases. The animals' blood-pressure was reduced by
aspirations of blood from the heart. The conclusions were that when
there was a loss of 20 per cent of blood the amount of oxygen required

1 Canadian Medical Association Journal, September, 1917, 7, 769.

2 Lancet, June 4, 1921, 1, 1173.

3 Journal of the American Medical Association, 1922, 79, 375.

4 American Journal of Surgery, October, 1921, 35, 109.

224 LEE: SURGERY OF THE EXTREMITIES

was from two to three times greater than it was before exsanguination,
and that after 25 per cent loss the oxygen requirement was five times
greater than it had been before. Cannon made similar observations
on shocked soldiers. Oxygen starvation means acidosis, the hemoglobin
is low and final oxidation of the acid derivatives of metabolism is incom-
plete. Patients with cardio-renal changes are the most serious risks,
since they demand more than the normal volume of oxygen in their
tidal air, and slight degrees of asphyxia may produce a fatal increase in
acidosis or a disastrous degree of heart strain.

Heat Losses of the Body Connected with Surgical Operations Under
Ether Anesthesia. Corlette1 compares the physical appearance of
patients under ether with persons doing muscular work. He made an
attempt to gain an approximate idea of the quantity of heat that may
be lost by a patient under ether. In default of measurement, he assumed
that a reasonable working approximation might be estimated from com-
parisons with work. The maximum possible heat loss per 1000 liters
(expiratory measurement) for any respired atmosphere not below freez-
ing-point is 29.07 calories. At 20° C. the maximum is 23.86 and the
minimum. 14.74 calories. The heat loss caused by the warming of the
vapor of 100 cc of ether from 0° C. to 33° C. (the temperature of expired
air) is only 0.9 calories. These figures are compared with the total
heat loss of 273 calories per hour for a man at moderate work and 105
calories per hour for resting. Therefore the cooling effect of cold ether
vapor being quite insignificant, it is not reasonable to regard it as a
cause of ether pneumonia. No heat loss can occur by respiration if
the air is saturated with moisture and wrarmed to 33° C, and a similar
condition of the atmosphere also completely blocks heat loss from the
skin. This indicates the way for control of heat loss from either channel.
He presents convincing figures showing the great increase in heat loss
from the skin that is induced by even a slight current in the atmosphere.
For preventing heat loss the optimum condition of atmosphere for an
operating room is one of comparative stillness and reasonably high
moisture content and temperature. The forms of warmed ether
apparatus in common use dry the air. The extra heat loss caused by
respiration of dried air more than counterbalances the effect of warming,
and moist air should therefore be used. Warmed blankets maintain
near the skin a water-saturated atmosphere at tropical temperature,
preventing evaporation. The stored heat in four large blankets taken
together amounts to 13.6 calories for each 10° rise or fall of tempera-
ture. Much of the heat is wasted into the air of the room or into the
mattress. Heat cannot be absorbed into the body from hot-water
bottles; they can only block heat loss. Safe electric warmers, suitable
for warming, can be contrived, and they could usefully replace hot-water
bottles.

Death following Ethyl Chloride Inhalation Anesthesia. Recently,
articles concerning this anesthesia have classified it as without danger
for short periods or for the initial stage of an ether or chloroform anes-

1 Medical Journal of Australia, August 13, 1921, 2, 115.

LOCAL ANESTHESIA 225

thesia. llenner reports a death in a soldier, aged twenty-five years,
where 5 cc of ethyl chloride were used; and Hartlief, a sudden collapse
and death of a woman, aged twenty-five years, after the inhalation
of only 20 drops; and a second ease in a man, aged forty-six years, after
40 drops. Jaeger1 reports a healthy man, aged forty years, with a
normal blood vascular system as determined by physical examination;
there was a question of possible malignancy of a large chronic ulcer.

Local Anesthesia. The subject of local anesthesia receives more
and more attention each year. The foreign literature for some time
past has been filled with it, and their experience has been sufficient,
and over a length of time, to develop the mortality and unpleasant
complications which should not be overlooked.

By-effects and After-effects of Local Anesthesia.2 Wiedhopf
remarks that the symptoms from mild and transient toxic action of
procaine are generally overlooked, or are ascribed to the patient's
nervousness. But absorption of the drug may induce vomiting, palpita-
tion, dizziness and sweating or collapse, agitation or somnolence, or even
death. Collapse has been exceptionally observed with simple nerve-
blocking— as for a herniotomy— with lumbar, sacral, paravertebral or
splanchnic regional anesthesia. Hartel has reported a case of syncope
during anesthetization of the Gasserian ganglion. Epileptiform seizures
after high sacral anesthesia have been reported by four surgeons, to
a total of 12 cases. Wiedhopf's list of fatalities in connection with
local anesthesia begins with 2 deaths at goiter operations under para-
vertebral and others under high sacral anesthesia— a total of 14 fatali-
ties, for which the procaine seemed certainly responsible. The extreme
vascularization of the extradural space provides a huge surface for
absorption of a fluid injected. The high pressure required to force the
anesthetic into the sacral canal might force it mechanically into the
circulation. In many of the toxic cases reported, it is mentioned that
blood had dripped from the needle, showing that a vessel had been
pierced. This seems to have occurred more often with the sacral,
paravertebral, splanchnic and trigeminal technics than with others.
Absorption of the drug is more likely in loose and highly vascularized
tissue; Lawen had toxic symptoms in 2 operations involving the anus.

Wiedhopf reviews further the articles that have been published relating
to toxic after-effect, citing instances of necrosis of the skin with sacral
anesthesia; transient blindness (2 cases) after trigeminal anesthesia;
paralysis after blocking a plexus, or injury of pleura or lung (Cappelle's
case of fatal injury of lung), pneumothorax, pleuritis, mediastinal
emphysema or air embolism. With paravertebral anesthesia, injury
of the vertebral artery, transient irritation of the vagus or sympathetic,
paralysis or injury of the pleura or kidney. With blocking of the
splanchnic nerve, injection of the fluid into a vein or injury of some
organ. With nerve blocking in the thigh, injury of the femoral artery.
Xo after-effects have been reported as following parasacral anesthesia.
It is disappointing to find that local anesthesia has not reduced the
after-pains from the operation itself.

1 Zentralbl. f. Chir., July 30, 1921, 48, 1073. 2 Wiedhopf, O. (p. 392).

226 LEE: SURGERY OF THE EXTREMITIES

Accidents with Spinal Anesthesia.1 Hertz injects 0.25 cc of
caffeine subcutaneously for prophylaxis after the injection of the anes-
thetic, and at the slightest sign of mydriasis, pallor or relaxation of the
sphincters, he repeats the injection of caffeine. If the symptoms are
grave, he injects the caffeine directly into the spinal canal and lowers
the head. Artificial respiration keeps dogs alive during the syncope until
the toxic drug is eliminated. This may require an hour or two, but then
the dog comes to life again. All who have reported meningeal accidents
have mentioned their actual mildness in marked contrast to their
apparent gravity, ranging from a simple meningeal reaction to an
aseptic puriform meningitis. Under an evacuating puncture and the
ordinary measures, the cure was complete in a few days. Saline infu-
sion combats the symptoms from hypotension, while hypertension yields
to lumbar puncture. The pressure in both blood and fluid should be
recorded.

Indications for Spinal Anesthesia.2 Gosset and Monod report
that at the Salpetriere, during 1921, ether was used for only 300 opera-
tions, nerve-blocking in 71, chloroform in 3 and spinal anesthesia in 442
cases. Spinal anesthesia is reliable for operations below the thorax, and
they have never had a fatality in more than 2000 applications of it.
The headache with it is sometimes annoying and persisting; syphilitics
seem particularly liable to this. It is particularly advantageous for
the elderly, but they reject it for tuberculous subjects and where there
is already a low blood-pressure and temperature. They had 2 fatali-
ties where ether was given to supplement the defective anesthesia.

Preoperative Care. In acute surgery, water, according to Crile,3 is
perhaps our most potent therapeutic agent, for water has a greater
specific heat than any other substance; water has the greatest solvent
power; water has the greatest power as a catalyst; water is the only
medium in which colloidal systems can be established; water itself is a
chemical activator.

It follows that water is a primary essential to the organism.

The well-being of the organism, as a whole, depends upon the state
of its constituent cells; the state of the constituent cells depends upon
the maintenance of their respiration; the maintenance of internal
respiration of the cells depends upon the preservation of the acid-alkali
balance and the resultant difference in potential between the nucleus
and the cell body, and upon the degree of permeability of the selective
semipermeable membranes of the cells. The maintenance of the
essential properties of the cells—the preservation of their internal
respiration— demands a medium with the qualities listed above, that
is, water— fresh water.

We are prone to forget that man is a multiple descendant of his
ancestral water-born unicellular marine organism ; that man has emerged
through evolution from the sea, bearing the formula of the sea, and
that some parts of his body are almost as liquid as the sea; that he is a
landed marine animal, obeying the laws of the sea.

1 Herts, J. (p. 214). 2 Paris medicale, March 11, 1922, No. 10.

3 Editorial, Surgery, Gynecology and Obstetrics, 1922, 34, 277.

POSTOPERATIVE COMPLICATIONS 227

Water, therefore, is the vehicle in which the mechanism of man is
suspended, and without fresh water it cannot exist.

It follows that a patient should have water at every stage of his
progress. He should have it early before the progress of the disease, or
the trauma of operation may have disturbed the internal respiration of
the cells. To assure the efficient watering of the cells, water should be
given by each and every route that will assure its reaching the cells—
by mouth, by rectum, by hypodermoclysis; in sufficient quantities—
2000, 3000 and 4000 cc each twenty-four hours— and continued day
after day until recovery or death.

If the patient cannot receive water, if his tissues fail to absorb and
use water, it does not mean that water has failed; it is a sign rather
that the organism has failed, and that irrevocable dissolution is in
progress.

Water early, water continuously, water late— water— fresh water
always— is a fundamental requirement of restoration and of conserva-
tion of the mechanism.

Postoperative Complications. Postoperative complications receive
more than their usual share of this year's literature. Acidosis still
is under discussion.

Ross1 states that following the adoption of a more liberal diet before
operation, elimination of the purgative and the earlier and more gen-
erous postoperative feeding, the number of cases showing postoperative
acetone and diacetic acid in the urine has decreased. This agrees with
our clinical experience.

Vaughan and Van Dyke have published a timely paper upon post-
operative therapy, and we feel that it is of such importance that it is
quoted freely.

Postoperative Dietotherapy. Vaughan and Van Dyke2 state
that prior to the middle of the nineteenth century the dietetic treat-
ment of most acute disease conditions consisted in virtual starvation.
Graves, in 1848, first insisted that a fever patient should be fed. Today
clinicians are in accord regarding dietary treatment of febrile condi-
tions. The high calorie treatment of typhoid fever is a more recent
development, but its value has been demonstrated beyond cavil.

The surgeon notoriously pays less attention to dietary treatment
than does the internist. In many surgical clinics postoperative treat-
ment still consists in partial starvation. The desire to prevent nausea
and vomiting results in undue caution.

The treatment of operative cases begins before operation. It is
frequently advisable to keep the patient in bed for some days prior to
operation, in order to build up the general resistance. A light, highly
nourishing diet, relatively rich in carbohydrates, may be given up
through the day preceding operation.

The importance of a liberal fluid intake before operation cannot be
overemphasized. The prevention of shock depends, in part at least,
on the maintenance of a normal blood volume. The practice still

1 American Journal of Surgery, October, 1921, 35, 121.

2 American Journal of the Medical Sciences, 1922, 163, 272.

228 LEE: SURGERY OF THE EXTREMITIES

occasionally in vogue of withholding fluids for some hours previous
to operation results in preliminary dehydration, and renders the body
less able to combat shock when it occurs.

Following operation, the patient usually receives nothing by mouth
during the first twenty-four hours. During this period the stomach is
usually upset, and there is a strong tendency to nausea and vomiting.
If these symptoms are absent, there is no reason for protracted with-
holding of food. The administration of fairly abundant fluids before
operation frequently lessens the tendency to nausea and vomiting.
Another precaution, which is frequently successful, is that of washing
out the stomach while the patient is still under the influence of the
anesthetic. As soon as the stomach will tolerate ingested material,
fluids may be administered. It is best first to try out the patient
with water or with weak tea, or, if stimulation is necessary, strong coffee.
Usually by the second day the patient is in condition to take liquid
nourishment. Sometimes this occurs sooner.

The liquid dietary used in most surgical clinics, and also in many
even of the more progressive medical clinics, is based upon two essential
food substances: Milk and raw eggs in the form of egg-white, albumen
or eggnog. Milk is frequently contraindicated in postoperative con-
ditions because of the tendency to distention, and therefore albumen
water is often the chief constituent of liquid diets. Scarcely any food
substance is less fitted to be the principle article of diet than is uncooked
egg-white.

The popularity of this article in treatment arose from the classic
work of Beaumont, who found that raw egg-white left the stomach
more rapidly than did any other food, and concluded that it was more
rapidly digested. Little attention has been paid to more recent work
demonstrating that this rapid emptying occurs because raw egg-white
is not digested at all in the stomach.

They sum up the case against uncooked egg albumen in saying: (1)
That it is very poorly digested and absorbed; (2) that as high as 50
per cent is lost in the feces; (3) that it tends to produce gastro-intestinal
upsets; (4) that at times it appears to produce an albuminuria, a con-
dition certainly not to be desired in postoperative cases in which the
kidneys already are overworked, as evidenced by the frequency of
albuminuria following general anesthetization. All of these disadvan-
tages are eliminated by the simple process of coagulation.

While egg-white is principally protein, the preponderating element in
the food of postoperative cases should be carbohydrate. During opera-
tion the metabolism is usually increased and the reserve supply of
carbohydrate in the body is, to some extent, depleted. Carbohydrate
should now be administered to furnish additional energy and to protect
the patient's own body protein. If protein alone is given, the basal
metabolism increases as a result of the specific dynamic action of pro-
tein. Protein so stimulates the metabolism that the rate of heat
formation in the body is accelerated. Sugars and fats have a similar
dynamic action, but to a much less marked degree.

Most patients, after undergoing an operation and postoperative treat-

POSTOPERATIVE COMPLICATIONS 229

ment, leave the hospital weighing decidedly less than upon entry. It
seems reasonable to hope that under proper dietary care these patients
may do equally well as those treated by high-calorie, high-carbohydrate
diets in typhoid fever, and that individuals may leave the hospital
weighing as much as, or more than, upon entrance. If this is to be
attained it can best be done by feeding diets of relatively high caloric
value and relatively high in carbohydrates.

It is, nevertheless, essential that sufficient protein be administered to
repair the waste and loss of protein from the body tissues. Chittenden
has shown that with slightly less than 1 gm. of protein per kilogram of
body weight the amino-aeid requirements of the tissues will be safely
met. The average adult individual weighs about 70 kg. With 1 gin.
of protein necessary per kilogram of body weight the daily diet should
then contain approximately 70 gm. of protein. This will contribute
about 2S0 calories to the daily requirement, and we must rely upon car-
bohydrates and fat for the balance. It makes little difference which
of these two latter substances preponderates as long as the fat does not
furnish more than 90 per cent of the non-protein calories. In view of
the tendency to acidosis in postoperative cases, as indicated by the
presence of acetone in the urine, it would appear more rational to utilize
carbohydrates in preference to fats.

Different proteins vary greatly in their ability to maintain nitrogen-
ous equilibrium. This is because certain ones, such as those from
cereals, are deficient in one or more of the essential amino-acids. Van
Slyke remarks that a man who might be kept in equilibrium on 4 gm.
of nitrogen per day, in the form of beef, milk or eggs, would require 8
gm. as bread or potatoes and 16 gm. as beans. Thus, it would appear
advisable, when we are giving proteins, to give those of higher value,
such as meat or meat derivatives, milk, eggs and fish. We must differ-
entiate between proteins of good quality and those of poor quality.

It is not enough that a diet possesses sufficient calories and is com-
posed of the right proportion of foodstuffs. Sufficient vitamins must
be present. The food must be palatable. There must be sufficient
variation so that the diet will not become irksome. The food must be
so prepared that it is easily digested and absorbed.

The physical texture and the fineness of division are factors worthy
of consideration. In general, the more finely divided the food, the
more rapidly does the digestive juice penetrate, and the more rapid y
does digestion take place. Indigestible solids not only act as stimulants
to peristalsis, but apparently actually retard normal absorption. The
method of cooking is important. Fried substances are covered by
a layer of material which the gastric juice can neither readily dissolve
nor penetrate.

If the diet contains a fairly abundant proportion of milk and of
eggs, whose albumen has been coagulated, there is little danger of
deficiency in vitamins, either in the fat-soluble A or in the water-
soluble B.

Palatability depends on: (1) Variation and (2) the type of food
administered. Only two food substances are naturally appetizing and

230 LEE: SURGERY OF THE EXTREMITIES

do not require seasoning. These are animal foods and fruits. The use
of fruit juices for increasing palatability is well known. The addition
of meat extracts for the same purpose may be employed.

REFERENCES.

1. Bateman, W. G.: The Use of Raw Eggs in Practical Dietetics, American
Journal of the Medical Sciences, 1917, 153, 841.

2. Friedenwald and Ruhr ah: Diet in Health and Disease, W. B. Saunders Co.,
Philadelphia, 1909.

3. MacLeod, J. J. R.: Physiology and Biochemistry in Modern Medicine,
C. V. Mosby, 1919, 2d ed.

4. McCollum, E. V.: The Part Played in Diet by Food Substances of Unknown
Nature, Oxford Medicine, 1920, 1, 435.

5. Mendel, L. B.: Food Factors in Gastro-enterology, American Journal of the
Medical Sciences, 1919, 159, 297.

6. Van Slyke, D. D.: The Chemistry of the Proteins and Their Relations to
Disease, Oxford Medicine, 1920, 1, 251.

Acute Dilatation of the Stomach as a Postoperative Condition
is carefully reviewed this year by Wilensky,1 and was considered at
length in our review in 1921.

The increasing references in literature we feel are a sign of its more
frequent recognition, rather than increased incidence. But as yet the
hospital surgeons see no evidence in their interne physicians that the
importance and symptoms of the condition are being taught in the
medical schools.

Xeiden2 states that to date no one has succeeded in reproducing acute
paralysis of the stomach in animals, although severing the vagus on
both sides below the diaphragm is followed by stretching of the fundus
of the stomach and retarding its evacuation.

The mortality in the latest series published keeps as high as ever,
as is seen by his tabulation of the cases published since 1911, 50 per
cent of the 36 cases terminating fatally. In 46.2 per cent of the fatal
cases the acute paralysis of the stomach was a postoperative compli-
cation.

One important practical conclusion from his research is the warning
of the danger of morphine in postoperative stomach disturbances and
in acute paralysis of the stomach. Morphine promotes secretion in
the stomach in addition to its other action, and hence it adds to the
load the stomach is already carrying.

This is an interesting observation for several of the assistants working
with two surgeons, one routinely using morphine pre- and postopera-
tively and the other avoiding it before operation and allowing it spar-
ingly after, have remarked that acute dilatation of the stomach occurs
more frequently when morphine is used.

As to the treatment, only two courses are followed at the present
time: Posture and gastric lavage.

During the last year we have successfully employed the duodenal
tube instead of the dreaded stomach tube and feel that it is a decided
advance. It is easily introduced, even in young children, and can

1 Progressive Medicine, June, 1922, p. 76.

2 Arch. f. klin. Chir., Berlin, November 17, 1921, No. 2, 117, 338.

POSTOPERATIVE COMPLICATIONS 231

be allowed to remain for three to six hours if accessary. Tims a con-
tinuous drainage or syphonage can be obtained instead of the inter-
mittent Lavage of the stomach tube.

The suggestion of Cutler and Hunt, which we discussed last year,
that postoperative pulmonary complications are in the majority of
cases due to embolism from the operative field, is receiving more favor-
able consideration.

Postoperative Lung Affections and Their Prevention. In
preantiseptic days, elevation of temperature occurring after operations
was considered to be due to the healing processes of the wounds. Today,
while operative methods exclude the possibilities of wound infection
more and more, considerable attention is devoted to the postoperative
lung complications. Xandl,1 from a study of the material from Hoch-
enegg's Clinic, in Vienna, found a rather interesting difference between
the frequency of the lung complications in patients operated on under
general and under local anesthesia. Lung complications after goiter
operation were less frequent when local anesthesia was employed.
The method of anesthesia had no effect upon the operative results of
hernia operation, and in stomach operations more depended upon the
operation than upon the method of anesthesia.

The occurrence of lung complications after resections was more
frequent than after gastro-entero-anastomosis. The incidence of lung
complications appears to be almost the same in local and general anes-
thesia; howTever, fatal postoperative involvements were less frequent
following local than following general anesthesia.

The possibility of postoperative lung complications decreased with
the increasing distance of the operative field from the diaphragm. In
1379 cases of hernia and abdominal operations, postoperative lung
complications occurred in 14.5 per cent; in 1585 cases of operations on
the head, neck or buccal cavity, extremities, breast and rectum; the
occurrence of postoperative lung complications was only 8.5 per cent.

Norris2 reports a survey of 56,000 operations: 40,000 general opera-
tions showed a pneumonia morbidity of 1.1 per cent and a mortality
of 0.4 per cent, while in 16,000 abdominal cases the pneumonia mor-
bidity was 4 per cent.

We have noted in the past the higher rate of complications reported
in the foreign literature than in the American.

Postoperative Massive Collapse of the Lungs. Hirschboeck3
calls attention to the subject of massive collapse of the lungs as a post-
operative complication having scarce mention in American medical
literature up to the present time, and only by English and Canadian
authors. He believes that it undoubtedly occurs very commonly
both in civil and military practice, and is frequently confused with
other more or less common postoperative pulmonary complications,
such as pneumonia, pleuritis, pleural effusions, etc.

Attention was first drawn to the occurrence of massive collapse of

1 Deutsch. Ztschr. f. Chir., July, 1921, Nos. 1-2, 165, 67.

2 Illinois Medical Journal, October, 1921, 40, 288.

3 Surgery, Gynecology and Obstetrics, 1922, vol. 67.

232 LEE: SURGERY OF THE EXTREMITIES

the lungs by W. Pasteur,1 who cited 34 cases as occurring with post-
diphtheritic paralysis of the diaphragm or other accessory respiratory
muscles in 1890. It is interesting to note that Pearson-Irvine, in 1870,
made the observation on cases which undoubtedly were cases of massive
collapse, "That the physical changes observed in the lungs were the
result of paralysis of the muscles concerned in the elevation and expan-
sion of those parts." In a later series of 64 cases of postdiphtheritic
phrenic paralysis, with 15 fatal results and with autopsies on 8 of these,
Pasteur was able to demonstrate the gross pathology in 5, the others
proving to be cases of bronchopneumonia. The cases were all bilateral,
in a more or less advanced collapse, and all presenting the same char-
acteristic en grosse, the parts being entirely devoid of air, of a deep,
definitely circumscribed blue color and sinking entirely in water.
Pasteur noticed the similarity in the symptomatology between numer-
ous clinical cases developing postoperatively and these cases of post-
diphtheritic paralysis with collapse of the lung. In 1908, in the Brad-
shaw lecture before the Royal College of Physicians, he drew attention
to the condition, since which time he has encountered an increasing
number of these cases and a corresponding diminution in those of
postoperative pneumonia. The clinical features were accurately de-
scribed, the diagnosis elaborated and in 19142 he published an article
drawing attention to its frequency. Of 201 lung complications out
of 3559 cases, in the Middlesex Hospital between 1906 and 1910, he
found 12 cases of massive collapse, with 1 death; in frequency, less than
pneumonia, bronchitis or dry pleurisy, but more common than embolism,
abscess or pleural effusion. It was found to occur with all methods of
anesthesia, and occurred following operations on all areas of the abdo-
men.

About the same time Pasteur wrote his contribution in 1914,
Dingley and Elliott published an article3, inspired by Sir Rickman
Godlee, who showed them several cases encountered in his practice.
During a period of two years the writers observed 11 cases, all of which
followed abdominal operations. Their contributions to the literature
is noteworthy chiefly on account of their consideration of the possible
cause of this condition. They recalled Lichtheim's4 observations, made
in 1878, in which he had produced a condition similar in rabbits by
introducing laminaria plugs into the bronchi, resulting in a collapse of
the lung tributary to the bronchus, which was the subject of the experi-
ment. Dingley and Elliott conclude that in man, in addition to the
comparative immobility of the thoracic wall, secretion blocks the smaller
bronchioles, with the result that collapse ensues, just as in Lichtheim's
animal experiments. Pasteur postulated an active collapse of the lungs,
with an absence of any obstruction to the air passages, which he thought
was induced by reflex inhibition of the diaphragm. He believed the
collapse, to put it simply, to be due to alveolar expulsion rather than
alveolar absorption.

1 International Journal of Medical Science, 1890.

2 British Journal of Surgery, 1914, vol. 1.

3 Lancet, London, May, 1914.

4 Arch. f. exper. Path. u. Pharm., 10, 54.

POSTOPERA TIVE COMPLICATIONS 233

Rose Bradford1 devotes a chapter to the consideration of this subject
in a recent "System of Medicine," in which he refers largely to previous
articles written by him2 in 1918 L919. His experience was largely
with military practice, with a large incidence, particularly in gunshol
wounds of the chest, in which injuries he believes it occurs in 5 to 10
per cent of the cases. Jle points out that in gunshot wounds of the
head or arms massive collapse has not been known to occur, but is
occasionally seen as a complication in wounds of the buttocks, pelvis
and thighs, assuming therefrom that the degree of immobilization is
a factor in its production.

Briscoe,3 in 1920, emphasized the effect of deficient respiratory
excursion and a recumbent posture in causing diaphragmatic fixation
with pleuritis and coincidently pulmonary deflation.

Recently, Scrimger,4 in his article speculates on the various theories
heretofore promulgated regarding the causation of massive collapse,
and adds his belief that the lesion is probably due to an abdominal
interference with the vagus control, causing a contraction of the mus-
cular elements of the lung, aided by the subsequent collection of mucus
in the bronchi sufficient to prevent the egress of air and leading to
absorption of the alveolar air content and ultimately collapse. His
article is interesting, particularly on account of the roentgenographies
studies, which in some of his cases show- most extravagant alterations in
the relationship between the intrathoracic organs.

Ilirschboeck believes that various factors may produce the lesion
and that they are probably never entirely single, except in postdiph-
theritic paralyses, in which the immobility of the diaphragm is so
extreme as to be strikingly conclusive as to its being the cause. One
must bear in mind that on the one hand Lichtheim's experiments are
difficult to refute with his careful experimental technic, whereas on the
other hand the evidence offered by postdiphtheritic phrenic paralysis is
equally incontrovertible. There is no doubt that the recumbent
position, as emphasized by Rose Bradford and Briscoe, is an important
subsidiary factor as well as deficient aeration of the lungs. It is prob-
able that in civil practice the incidence is more common in abdominal
surgery, leading to more or less fixation of the diaphragm, due to a
reflex inhibition, with an effort to cause a splinting action on account
of the neighboring trauma. The theory that the recumbent posture is
a factor is corroborated by the non-occurrence of massive collapse in
injuries not requiring immobilization of the body, such as injuries to
the head and arms, as observed by Rose Bradford. The admonition
to take deep-breathing exercises systematically after operations would
not only promote aeration of the more distal parts of the bronchial
tree, but would also tend to reduce the immobility of the perithoracic
musculature. I think it reasonable to assume that, with the lack of
mobility in the accessory muscles of respiration and the diaphragm,

1 Oxford Loose-leaf Medicine.

2 Quarterly Journal of Medicine, 1918-1919.

3 Ibid., 1920.

4 Surgery, Gynecology and Obstetrics, 1922, No. 6, vol. 32.

234 LEE: SURGERY OF THE EXTREMITIES

pulmonary expansion and retraction arc necessarily limited. Mucus is
tunned and not expelled, causing an obstacle to the ingress of air into
the smaller bronchioles, leading to ultimate alveolar absorption of the
air into the circulation.

Bronchial obstruction, therefore, and muscular immobility tend to
bring about this condition, one factor or the other predominating,
however, in individual cases, leading to alveolar absorption, and finally
to the condition of massive collapse.

The extent and the site of involvement in massive collapse vary con-
siderably. In most cases there is only a partial involvement of one of
the lower lobes of the lungs; in others the condition is more extensive,
involving a whole lobe or even an entire side. It is rather frequently
bilateral. The noteworthy feature is the fact that, in unilateral trauma,
collapse occurs not only on the side affected, but oftentimes on the
contralateral side, as was pointed out by Rose Bradford and others.

Physical Signs and Symptoms. The physical signs and symptoms of
massive collapse are so distinctive that it is curious that the condition
has not been recognized more commonly and described more frequently.
A careful study of the case will make differentiation from conditions
simulating it very easy. The exciting factor varies a great deal and
any trauma, either accidental or otherwise, necessitating more or less
immobilization of the body may bring about the condition. It has
been known to follow all methods of anesthesia, has occurred with local
anesthesia and without any anesthesia at all. Aside from military
practice, I believe that in civil life it will be found that abdominal
operation is the most frequent cause of the condition, on account of
its immediate effect in requiring immobilization, producing immobility
of the diaphragm and deficient aeration of the lungs. The condition
may develop within a few hours or as late as one week after the exciting
trauma. The onset is sudden, the course either rapid or at times pro-
tracted and resolution either prompt or slow. The degree of tempera-
ture is usually very moderate, but may be as high as 103° or 104° F.,
the coincidence of inflammatory phenomena probably influencing the
height of the temperature curve. The respiration rate is increased by
the immobility of the affected part, by an accompanying pleuritis or
by toxic conditions incident to inflammatory complication. The pulse-
rate is found to be more or less in direct relationship with the respira-
tory and thermic changes, but is less marked in uncomplicated cases,
as would be naturally inferred.

On examining the chest, one is impressed by the diminished or absent
excursion of the chest wall over the affected area. The cardiac impulse
is displaced toward the affected side, and is as marked in the left-sided
cases as in those occurring on the right side, the apex having a tendency
to tilt outward and upward, so that the apex-beat may be felt in the
axilla. In right-sided affections the impulse may be felt at the tip of
the sternum or to the right of it. These signs are corroborated by
roentgenographic study, the heart retraction being most marked, the
dome of the diaphragm ascending to an unusual degree and the pul-
monary area appearing partially or totally collapsed. In bilateral

POSTOPERATIVE COMPLICATIONS 235

affections the displacement of the hearl is absent, but the high position
of the diaphragm and the collapse of the lungs arc easily manifest.
On palpation, the intercostal spaces on the affected side arc found to
be narrowed, leading to a relative approximation of the ribs. The
percussion note over the affected area is dull and may approach
flatness. Rose Bradford points out that in left-sided cases the lower
part of the chest wall is highly resonant, due to the abnormally high
level of the diaphragm, the liver interfering with this symptom in right-
sided eases. Breath sounds and fremitus are usually increased, some-
times enormously so, hut may be diminished or absent. The trans-
mission <>f voice sounds may be so intense as to approach whispered
pectoriloquy.

Bronchophony was present in all of my cases, and in no case was
there diminution of the breath sounds or fremitus. Xo doubt the
alteration in the transmission of sounds is due to the relative proximity
of the affected area to sound-conducting bronchial tubules. Rales arc
usually absent in the early stages, but supervene as the case progresses,
probably due to a bronchitis, resolution or an occasional pneumonia
developing. In a great many cases a pleural friction rub is plainly
audible. In the later stages of the condition, when expectoration is
rather profuse and resolution occurs, rales are more frequent. As
resolution occurs, the heart gradually returns to its original position,
the lungs slowly expand and the diaphragmatic dome flattens out.

The extent of the symptoms and the ease of recognition depend, of
course, upon the amount of lung tissue involved and as to w'hether the
condition is unilateral or bilateral. It is readily understood also that
the influence of the condition on the patient's economy is dependent
largely upon complicating factors, as well as upon the extent of the
lesion. Dyspnea may be moderate or extreme, as it usually is in
bilateral cases. The cough is slight, as a rule, in the beginning, with a
rather scant expectoration, but in the later stages it is accompanied by
an expectoration of profuse mucopurulent sputum. My experience
bears out the previous observation that the sputum is rarely, or never,
bloody— an important consideration in the differentiation between
pneumonia or infarct and collapse.

Bronchitis, pleurisy and pneumonia are recognized as complications.
Effusion has been known to follow pleurisy. A differentiation must be
made between pneumonia, hypostatic congestion of the lungs, embolus,
infarct, pleuritis (with or without effusion), hemothorax and massive
collapse. When one bears in mind the outstanding pathognomonic
signs of massive collapse, confusion with other conditions is difficult.
One must bear in mind that the affected side is retracted and does not
expand with inspiration. The diaphragmatic and cardiac displacement
is extreme and the general symptoms invariably less severe than with
pneumonia or embolus. The very marked dulness, the extreme increase
in the breath sounds (as usually noted), the scant expectoration, the
comparative absence of constitutional signs in the non-occurrence of
complications, accompanied by displacement of the heart and diaphragm
and roentgenographic studies, easily established the diagnosis.

The prognosis is invariably good, but bilateral cases, or cases affect-

236

LEE: SURGERY OF THE EXTREMITIES

ing more than one lobe, are more apt to be fatal, particularly in debili-
tated subjects.

Fig. 10.— Appearance of chest, April 11. (Elwyn and Girsdansky.)

Fig. 11. — Condition, April 19. (Elwyn and Girsdansky.)

Elwyn and Girsdansky1 report a case of postoperative massive collapse
of the lung.

1 Journal of the American Medical Association, August 26, 1922, No. 9, vol. 79.

POSTOPERA TI VE COM PLICA TIONS

237

This case undoubtedly represents one of massive collapse of the right
lung, following a stal> wound in the abdomen. What part the wound
itself and what part the anesthesia played in the production of the
collapse cannot be determined.

***-

«3

Fig. 12.— Appearance, April 26. (Elwyn and Girsdansky.)

Fig. 13.— Normal appearance, May 10. (Elwyn and Girsdansky.)

238 LEE: SURGERY OF THE EXTREMITIES

Postoperative Thrombosis and Lung Emboli. That thrombosis
may be due to a predisposition of some sort on the part of the patient,
and not upon some postoperative phase of convalescence, is suggested
to Rupp1 from the examination of the thrombi found in 13,000 cadavers
dead of internal diseases. The factors governing thrombosis, such as
slowing of the blood stream from changes in the blood as well as
in the bloodvessel walls themselves, injuries to the intima and action
of ferments upon the blood are common to all cases. Von Zurhelle
states the collection of blood platelets behind the flaps of the valves
of the larger veins in regions where, for mechanical reasons, the blood
stream is slower, is the exciting factor.

Changes in the intima Rupp considers important because of the
absence of thrombosis in severe cases of arteriosclerosis where the
lining membrane is much altered. The blood platelets are the real
etiologic factor and in recent thrombi, free from fibrin, they compose
most of the structure, the red distal ends of the thrombus being due
to stagnation of the blood with resultant coagulation. Rupp claims
the changes in the blood due to infection have no influence on throm-
bosis. The agglutination of the blood platelets is due to chemical
factors, and if this agglutination is prevented by the administration
of hirudin, or similar substances, no thrombosis will occur even if all
other favorable factors are present. The circulation of blood is neces-
sary to bring new blood platelets for the construction of the thrombus
and, in contradiction to the present view, it is the fast blood stream,
and not the sluggish one, which favors platelet thrombosis. Injury
to the vessel wall heals by fibrin formation and the resulting thrombus
is soft and made up of many red blood cells, while the thrombus which
forms in the lumen is firmer and composed mostly of blood platelets.
The mechanical theory of Aschoff explains many of the unknown fac-
tors of thrombosis, but the injury to the vessel Avails is always a neces-
sary factor, as well as changes in the consistency of the blood-stream.
Slowing of the blood stream alone is not sufficient, otherwise we would
expect thrombosis in small venuoles where the blood-pressure is lowest,
and not in the larger veins where it is higher. The fatal thrombi
are most frequently found in the veins of the thigh and pelvis. Changes
in the blood stream, as it passes under the hypogastric artery, the
sacrum and Poupart's ligament have, no doubt, much to do with the
condition. Thrombosis in the thigh most commonly follows lapa-
rotomy and seldom from operation on the vessels themselves. The
enforced quiet and costal breathing from the pain following abdominal
operation deprives the blood stream of the great veins of much mechan-
ical assistance in reaching the heart. Abnormal conditions in the
heart, kidneys, bloodvessels and lungs predispose to the condition.
Rupp was unable to demonstrate a predisposition from infection.

Among 13,000 autopsies there were 057 cases of emboli or lung
infarcts, making 5 per cent of all cases. The number was equally dis-
tributed between men and women. Among 22,689 operations, 0.25

i Arch. f. klin. Chir., Berlin, March 21, 1921, 115, 672.

POSTOPERATIVE COMPLICATIONS 239

per cent died of thrombo-emboli; most cases occurred between the
ages of fifty and seventy years; the emboli occurred most commonly

during the first week; most often after abdominal section; and in the
left femoral and iliac veins about four times more often than in any
other locality. In a large number of cases other lesions of heart, kid-
ney, lungs or bloodvessels were demonstrable. Of 53,000 eases of death
from internal disease, 601, or f per cent, died of thrombo-emboli. The
age at which most cases occurred was between sixty and seventy years,
and about 18 per cent showed other pathologic lesions. Three hundred
and forty cases occurred in the femoral veins, 264 of which were on
the left side. The anesthetic seemed to have no effect upon the occur-
rence of thrombosis. Infection also is unimportant, as shown by the
absence of an increased frequency of thrombosis in cases of acute
appendicitis and incarcerated hernia when compared with non-infected
cases. As preventive measures, massage of the arms and legs, saline
infusions, lung gymnastics, heart stimulants and complete physical
examination of the vital organs are recommended.

Secondary Parotitis. Lynn1 states that this condition, while
not particularly common, is of sufficient frequency and interest to merit
an occasional study and review of the literature. It is a phenomenon
which has been associated not only with surgical procedures but has
been frequently met with when a strictly medical regimen has been
carried out. In reviewing the literature, it is quite interesting to note
the gradual elimination of factors formerly thought to play a part in
the production of this condition, and at the present time its etiology
seems unknown.

Pyemia, or embolism, has been discussed.

The duct-infection theory was first advanced, in 1889, by Hanau and
Fillet. They were the first to suggest the possibility of infectious
organisms traveling up the duct to the gland. To justify their opinion
they called attention to the pathologic findings, namely, inflammation
around the ducts and then spreading to the perilobular tissue; whereas,
if due to emboli the inflammation would first appear perivascular.
This was substantiated by the bacteriologic findings of Girode, who
found the organism mostly occurring to be the staphylococcus, pnett-
mococcus, pneumobacillus, typhoid bacillus, colon bacillus and the
streptococcus in the order of their frequency.

In cases of gastric and duodenal ulcers, Hone and Barton attached
more importance to antecedent hematemesis than oral starvation as a
factor in the production of secondary parotitis. This might be likely
only insofar as it leads to treatment by oral starvation, there being
no evidence that parotitis depends on the occurrence in the parotid
gland of thrombi, such as might be favored by a posthemorrhagic
leukocytosis.

The parotid contains lymph glands, the other salivary glands do not.
The presence of these favors the collection of infectious agents and the
setting-up of an inflammatory process.

1 Surgery, Gynecology and Obstetrics, March, 1922, No. 3, vol. 34.

240 LEE: SURGERY OF THE EXTREMITIES

Before dismissing the question of cause, there is one factor to which
Deaver calls attention, namely, " traumatism— the result either of
direct pressure on the parotid gland or the forcible manipulation of
the jaw by the anesthetist." But how many times have we seen cases
in which the administration of the anesthetic was difficult, and it was
necessary forcibly to hold the jaw, and yet this condition did not develop ;
and again we have seen this condition arise after a perfectly smooth
anesthetic. At the City Hospital, many of the patients were alcoholic,
the anesthetic in a great many cases difficult, and the occurrence of
this condition practically nil.

Inquiries made by Fisher show that traumatism of the bony or soft
structures of the face have had little, or nothing, to do with the pro-
duction of the condition. He says, "The results of such inquiries
have been negligible as to infectious parotitis." Our experiences bear
out this conclusion. If it has any bearing, it is only a minor role.

According to Blair, suppuration usually takes place in three or four
days, all symptoms being increased. Dyball finds that 33.33 per
cent of the cases are bilateral. When this condition is bilateral there
is usually an interval of two days before its occurrence on the second
side. The enclosure of the pus may rupture and the latter discharge
through the external ear, or it may force its way to the sternocleido-
mastoid muscle and travel downward to the supraclavicular and medi-
astinal regions. Retropharyngeal abscesses have been known to form
secondarily. The gland may become gangrenous.

Wagner claims that the mortality of these cases is 30 per cent.

Fenwick, in the treatment of ulcer by oral starvation, formerly had
a large number of cases develop suppurative parotitis. He tried various
mouth washes without success. He then resorted to the giving of
agents that would promote salivary secretion, at the same time not
stimulating peristalsis of the stomach qr intestines* After trying this
plan he treated more than 300 cases by rectal feeding without a case
of parotitis. When the condition does arise, the use of ice is recom-
mended (Blair); and when suppuration does occur, as it usually does
in three or four days, radical treatment by the incision of Blair, Lilien-
thal or Cope are recommended.

In this, one should not wait for fluctuation, but he should be governed
by the increase of symptoms.

Conclusions. 1. More attention should be paid to the condition
of the mouths of our patients, before and after operation. Following
operations, some mild salivary stimulant should be given to keep the
ducts clean.

2. The reason the sublingual and submaxillary glands are practically
immune is because they are mucous glands, mucin inhibiting bacterial
growth.

3. Furthermore, the parotid is the only salivary gland containing
lymph glands. These favor the collection of inflammatory agents.

4. There are two main sources of infection, viz.: (1) Through the
blood or lymph stream; (2) by way of Stensen's duct.

5. It is Lynn's opinion that the infection of the parotid in these

PERIARTERIAL SYMPATHETICUS 241

cases herein reported were oral, in view of the fact that in every instance
oral starvation was necessary for some days. Surgical treatment is
justified if symptoms do not subside by the third or fourth day.

Periarterial Sympatheticus. This work of Leriche1 has created a great
deal of clinical interest among surgeons, and as we ourselves have had
under observation 11 cases in the services of Gibbon and LeConte, at
the Pennsylvania Hospital, Philadelphia, our interest in the subject is
at least explainable. This communication was read by Leriche before
the American Surgical Association.

The sympathetic nervous plexuses included in the external layer of
bloodvessels seems to possess a real autonomy. The sympathetic
study of the phenomena, which follow the excitation of normal arteries,
reveals the existence of a very characteristic physiologic reaction which
never fails. When the sheath of an artery is pinched, the vessel con-
tracts, its pulse stops at once and its size diminishes. If the cellular
laver of the vessel is excised, it will diminish to one-third or one-fourth

Fig. 14. — 1, aspect of a normal capillary loop in a finger, examined by Weiss'
method; 2, diminution of size when the brachial peri-arterial nerve is excited; 3,
almost complete disappearance after ligature of the brachial artery. (Leriche.)

of its usual caliber. The segments on either side of the excision will
maintain their normal size unless their sheath has been injured. This
arterial contraction usually causes the pulse to disappear, but does
not altogether interrupt the circulation. If the artery is cut through
this contracted area, a thin thread of blood is seen inside, and, if the
capillaries are examined by Weiss's method (Fig. 14) at the moment
of arterial contraction, the capillary loops diminish regularly in their
whole length, become pale, but remain visible. Thus, arterial con-
traction is the primary element of the usual physiologic reaction
against excitation of the sympathetic nervous plexuses in the ad-
ventitial coat of the arteries. During the hours following the opera-
tion the limb is colder, and at times there is a difference of 3°
to 4° C. After three to fifteen hours, definite changes occur, which
Leriche calls the secondary symptoms. There is an elevation of the
local temperature of the part reaching 2° and even 3° C, while the
general body temperature is unmodified. The patient also has a

1 Transactions of the American Surgical Association, 1921, 39, 471,

242 LEE: SURGERY OF THE EXTREMITIES

subjective sensation of heat in the operative extremity. There is also
an elevation in arterial pressure, which may reach 4 cm. of mercury,
compared with the healthy side; this measurement of 4 cm. is found in
the original article in the Transactions of the American Surgical Asso-
ciation and also in the reprint in the Annals of Surgery (we feel that
he must mean mm.). The last phenomenon in the secondary signs
is an increase in the amplitude of the oscillations, as shown by the
sphygmomanometer. This vasodilation reaction is transitional and
it becomes attenuated from the fifth to the sixth day and disappears
after three to four weeks. This concludes what Leriche calls the
characteristic physiologic syndrome of periarterial sympatheticus
against excitation.

Pathologically, such excitation may occur in visceral arteries as well
as in arteries of the extremities, and may be produced by direct trauma
or indirect infections of toxic agents. Whatever the cause, as soon as
the periarterial sympatheticus is injured, the previously-described
physiologic reaction occurs. As to the changes in the visceral blood-
vessels, we know absolutely nothing of these reactions and they are
at present time theoretical only. In the extremities he differentiates
two groups of changes. In the first group the characteristic physiologic
action is pure, while in the second group there are certain variations.

Group I includes two characteristic examples : " Stupeur des arteres "
(the so-called causalgia of Weir Mitchell) and Raynaud's disease.
"Stupeur," or causalgia, Leriche considers an active secondary spasm,
due to sudden excitation of the adventitial arterial layer. It may
follow a woundless traumatism as well as that of a projectile. Leriche
feels sure that during the war this contracture was so intense in certain
cases that it led to gangrene because of insufficient circulation.
Undoubtedly, many unnecessary operations were done for this condi-
tion. Raynaud's syndrome is a typical disease of the vasomotor
sympatheticus. In certain cases the periarterial sympatheticus of a
whole limb seems to be excited, for the vascular contraction involves
even capillaries. The crisis in Raynaud's disease consists in the physio-
logic reaction of the periarterial sympatheticus to excitation, namely,
painful ischemia and consecutive dilatation.

In the second group the symptoms are not so clear-cut. In many
instances the initial cause is left indefinite, and the physiologic action
may consist of contracture of too long duration or of abnormally per-
sistent dilatation. Thus motoT, sensory, vasomotor, glandular and
trophic symptoms may occur. Local necrosis and sloughs, profuse
sweating or absolute dryness of the skin, cyanosis, local blue or white
edema, pain and muscular atrophy, all of which Leriche feels can be
explained by circulatory changes.

This leads Leriche to believe that the treatment of these vasomotor
or trophic troubles must consist in the modification of the peripheral
circulation by periarterial sympathectomy. The technic consists in
the isolation of the artery for 8 to 10 cm., and then to dissect the
adventitial sheath containing the sympathetic nerve trunks from the
artery until it is completely denuded. He has performed the operation
64 times during the last five years.

BLOOD-PRESSURE FINDINGS 243

1. In painful phenomena, as causaJgia, he has 5 excellent results in
9 cases. He recommends that it be tried in the painful crises preced-
ing the gangrene of obliterative endarteritis. It is in this type of
case that it has been used at the Pennsylvania Hospital. In 2 cases
of Raynaud's disease he obtained good results.

2. Abnormal muscular phenomena of the hypertonic type. In is
contractures following war wounds all the cases were much improved.
He warns against its tise in what is called Volkmann's ischemic paralysis,
which lie considers a focal necrosis of the muscle and a definite lesion
that nothing can modify.

3. In trophic disturbances leading to ulcers Leriche has found, perhaps,
the best results. In 12 out of 13 cases the operation was followed by
rapid healing, but relapse is possible if the cause of the trophic ulcer is
not removed, and the cause is not always removed by a sympathectomy.

4. Leriche's explanation of the action of sympathectomy is that
there is a local circulatory hyperactivity due to the vasodilatation.

A Case of Causalgia Treated by Decortication of the Artery. Turco1
reports a man, aged forty-two years, who had attempted to commit
suicide by cutting the radial artery. A year and a half later the patient
returned because of intense pain. The hand was then swollen and it
was almost impossible to move the fingers. The pulse at the wrist
was weaker than that on the other side. As the symptoms were evi-
dently sympathetic in origin, Leriche's operation was performed, the
sheath of the artery being excised for a distance of 7 cm. Complete
recovery from all symptoms resulted. This case, therefore, confirms
Leriche's hypothesis.

Blood-pressure Findings in Circulatory Disorders of the Extremities. In
an effort to arrive at a plausible explanation of certain circulatory dis-
turbances of the lower extremities, whose origin and mode of produc-
tion have been obscure, the blood-pressure findings of Bernheim2 have
not only been interesting, but may turn out to be of real significance.
The gangrene and the near gangrene one sees nowadays are customarily
differentiated into various groups— Raynaud's disease, arteriosclerosis,
diabetes (with arteriosclerosis), senility, thrombo-angeiitis, etc., accord-
ing to such clinical manifestations and etiologic features as they exhibit.
All of these conditions present many features in common; the treat-
ment, for the most part, is as unsatisfactory and as unsystematized
in the one as it is in the other, and the end-result is usually the same.
As far as the patient is concerned, it matters little what group he falls in.

In all circulatory disorders of the extremities, a narrowing of blood-
vessel lumens come to pass; gradually in most instances, suddenly in
a few. It may be due to some spastic condition of the vessels that is
at first of an intermittent character, but later becomes continuous, or,
as is more usually the case, there is a gradual disposition of material
from one cause or another in the wall of the vessel under the intima
or within the lumen itself, which eventually totally occludes the vessel.
In any case, an obstruction of varying degree is offered the flow of blood.

1 Policlinica, Roma, 1921, 28, 127, sec. chir.

2 Journal of the American Medical Association, March 18, 1922, No. 11, vol. 78.

244 LEE: SURGERY OF THE EXTREMITIES

This being the case, one of two things must occur: Either the amount
of blood that passes the obstruction becomes less, or, if the volume is
to remain as before, the pressure back of the stream must be raised.

Blood-pressure readings taken on patients suffering from a variety
of circulatory disorders of the extremities indicate that, far from exhibit-
ing a rise, many of them reveal a low pressure, extraordinarily low in
certain instances, while most of them present a normal pressure. Once
in a while a slight elevation is encountered. Almost never does one
see a real hypertension. The surprising part of this is that it is just
the opposite of what one might have expected, in view of the fact that
a compensatory elevation of blood-pressure is frequently seen in gen-
eralized arteriosclerosis and in certain forms of heart and kidney disease.

The relation of these findings to ischemic conditions of the legs may
be interpreted in two entirely different and distinct ways. It may be
argued, on the one side that in circulatory derangements, exhibiting
obstruction to the blood flowing toward the lower leg and foot, the
blood-pressure does not rise, the vis a tergo fails to increase, and so no
opposition is offered to the further encroachment of the disease process.
The result— unless successful treatment is given— is gangrene. On
the other hand, it is just as logical to suppose that in the vast majority
of disease processes affecting the bloodvessels of the extremities there
does occur a compensatory rise in blood-pressure and that, as a conse-
quence, the threatened and real gangrenes do not come to pass. Only
where this rise fails to materialize do we see the gangrenes. The latter
theory might well account for our failure to find these disasters among
the many hypertension victims. In my experience it is most unusual
to see a gangrene, or even a threatened gangrene, in one of these patients.
Bernheim suggested in the blood-pressure we may possibly have the
explanation of certain obscure features connected with the production
of the threatened and real gangrenes. Just why there should fail to
be a rise in pressure in these cases is a mystery. It may not be logical
to feel that it should come to pass, especially in a disorder that is,
perhaps affecting but one limb. Nature does so much, though, that we
are accustomed to expect the obvious thing from her at all times.

That a gradual narrowing bloodvessel lumen— whatever the cause
may be— is aided and abetted on its course toward total occlusion by
a thinned-out, slowed blood stream which has little or no force back
of it, no one can deny. Little roughened plaques, tiny cracks in a
stiffened intima, pin-point areas of disease, it does not require much of
an imagination to see them picking out of the slowly passing stream
first, perhaps, the platelets and then such other cell elements as may
be needed to form the finally occluding thrombus. Nor is it difficult
to understand why so many of these threatened gangrene patients
have such a poor collateral circulation, if one will only realize that
blind passages, collapsed tubes, can be opened up only by a blood
flow of real force— such as they do not seem to have. It follows, then,
that the blood-pressure element in all cases of threatened and real
gangrene is apparently of more importance than has heretofore been
recognized.

LARGE MYCOTIC ANEURYSM OF THE FEMORAL ARTERY 245

Obliterating Thrombo-angiitis. Gilberl and Coury] reporl ;i case
which they claim is the first, to be published in France and speak of
it as "non-syphilitic arteritis obliterans of the Jews." They note that
the affection seems to be restricted to the Jews from central Europe
In this case they amputated the foot. No reference whatever is made
to the work of Leriche.

Large Mycotic Aneurysm of the Femoral Artery Developing During the
Course of Subacute Infectious Endocarditis. Farley and Norris2 place on
record a large mycotic aneurysm of the femoral artery secondary to
an infected embolus thrown off from the endocardium of a patient

Fig. 15. — Diagrammatic camera lucida sketch X 30 of a section across the lesion
in the left femoral. The artery was split open and the edges of the split, s and s,
spread wide apart in the hardening fluid. L, lumen. There is no intima. The
heavy undulating lines, e and e, represent all that is still traceable of the elastica.
The media, m, m, is thickened by connective-tissue growth and by round-cell infil-
tration. The solid patches in it are the foci of calcification of Moenckeberg's sclerosis.
In places it lies naked to the blood current in the lumen, in places it is covered by
elastica, in places it is overlain by thrombi, mi. The adventitia a, a, is normal. At
A1 it goes over into the sheath and adventitia of the femoral vein.

The large thrombus, I, is quite fibrous at its attachment Tl, soft, shaggy and infil-
trated with pus, and round cells at its opposite attachment T2.

The mural thrombi, m t, m t, probably lay close to or were continuous with the
lower edge of the central thrombus before the vessel was opened, the larger portion
of lumen and the more normal vessel wall lying above it (in the drawing). Some
blood, b, settled on the vessel wall postmortem. (Floyd.)

suffering from subacute infectious endocarditis. The aneurysm devel-
oped while the patient was under observation and grew to such large
proportions that spontaneous rupture was feared. In order to prevent
this fatal event, obliterative aneurysmorrhaphy (Matas) was performed.
The patient presented a surgical problem at the time of the beginning
of her femoral aneurysm. Tumor, dolor, calor and rubor were so
marked that the question arose as to whether the lesion was an abscess,
which should be incised, or merely an aneurysm. Fortunately, opera-

1 Bulletins de la Societe medicale des hopitaux, Paris.

2 Transactions of the Ayre Laboratory Bulletin, 1922.

246 LEE: SURGERY OF THE EXTREMITIES

tion was deferred, and the true character of the tumor had manifested
itself when the case was first seen by the reviewer.

Aneurysmorrhaphy was done under local anesthesia, with digital
compression of the artery above the site of dilatation. Seven days
after operation a secondary hemorrhage occurred and the vessel was
resutured. The death of the patient was caused by pyemia.

Floyd1 reports a mycotic embolism of the femoral vessels, whose
unusual features were: (1) The large size of the sac, its wide venous
connection and the density of its walls, preventing its rupture and
enabling it to erode bone. (2) The extensive lesion inside the opposite
femoral, with ulceration and formation of an organizing thrombus, but
without any aneurysmal dilatation. These features appear to depend,
in part, on an infecting organism of low, but persistent, virulence,
which allowed time for extensive connective-tissue growth and, in fact,
may have stimulated it. This low virulence was evidenced by the long
duration of the illness, the late appearance of cardiac symptoms, the
character of the lesion in the muscle wall of the heart as well as of those
in the right and left femoral arteries.

1. Rokitansky: Handb. d. path. Anat., 1844, 2, 553.

2. Tufnell, J.: Influence of Vegetations on Valves of the Heart in Production
of Secondary Arterial Disease, Dublin Quarterly Journal of Medical Sciences, 1853,
15, 371.

3. Ponfick: Ueber embolische Aneurysmen, nebst Bemerkungen tiber das acute
Herzaneurysma Herzgeschwur), Arch. f. path. Ajiat., Berlin, 1873, 58, 528.

4. Thoma, R.: Ueber das Aneurysma, Deutsch. med. Wchnschr., 1889, 15,
309, 340, 361, 380.

5. Eppinger, H.: Pathogenesis (Histogenesis und Aetiologie) des Aneurysmen,
einschliesslich des Aneurysma equi verminosum, Arch. f. klin. Chir., 1887, vol. 35.

6. Unger, W. : Beitrage zur Lehre von den Aneurysmen, Beitr. z. path. Anat.,
1911, 51, 137.

7. Osier, W.: Gulstonian Lectures, 1885, 1, 469.

8. McCrae, J.: A Case of Multiple Mycotic Aneurysms of the First Part of
the aorta, Jour. Path, and Bacteriol., 1905, 10, 373.

9. Lewis, D., and Schrager, V. L.: Embolomycotic Aneurysms, Journal of the
American Medical Association, 1909, 53, 1808.

10. Simmonds: Mykotische Aneurysma der Aorta, Munchen. med. Wchnschr.,
1904, 51, 627.

11. Libman, E.: Embolic Aneurysms, Mt. Sinai Hospital Report, 1907, 5,
481, 488.

Richey and MacLachlan2 report 2 cases of mycotic emboli, one in the
superior mesenteric and the other in the posterior tibial artery. Both
were associated with a definite acute and subacute vegetative endo-
carditis of the mitral or aortic valves. In 1 case infarcts were found
in the spleen and kidneys. Streptococcus salivarius was isolated from
the blood streams of 1 case during life. No suggestion of syphilis was
found in either case at necropsy. Both aneurysms had ruptured, at
first slowly, with the formation of a false aneurysm. Clinically, the
rupture of the aneurysms was characterized by severe, sudden, lancinat-
ing pain, which persisted. From the evidence, it would seem that
both aneurysms had their beginning in an infected embolus.

1 Surgery, Gynecology and Obstetrics, 1921, 33, 560.

2 Archives of Internal Medicine, January, 1922, No. 1, vol. 29.

EMBOLI AND EMBOLIC GANGRENE 247

Operative Treatment of Femoral Thrombosis. Fasano1 reports the
exposure of the femoral artery 3 cm., below Poupart's ligament.
This revealed an organized thrombus, compact and adherent to the
vessel wall. It was forced out completely by manipulations, and the
blood flowed at once. The artery was sutured. The pulse became
perceptible in the foot; this did not last more than a day or two, but the
pains subsided and have not returned during the ten months since;
the gait is normal. The thrombosis evidently extended or reformed
below the field of operation, but the removal of the accessible thrombus
opened the passage into the deep collaterals. The circulation in these
was enough to insure the nourishment of the tissues and check the
tendency to gangrene.

Some years ago the reviewer assisted the late Francis T. Stewart in
the removal of a thrombus lodged at the bifurcation of the left common
femoral, with a result similar to that obtained by Fasano, a reforma-
tion of the thrombosis, and eventually it became necessary to amputate
through the middle third of the leg.

Embolectomy in Treatment of Embolism of the Extremities. Rey2 has
compiled 45 cases of embolectomy, the operation being a success in 9
of the 12 cases with an interval of less than ten hours; in only 2 of
the 5 with an interval of eleven to fifteen hours, and in 3 of 4 cases
with intervals of from sixteen to twenty or twenty to twenty-four
hours. As thrombosis develops below the obstruction so rapidly, the
outcome depends usually on the promptness with which the embolus
is removed. Secondary thrombi should be removed at the same time.
After removing the embolus the clamp on the artery above should be
loosened to allow the blood to sweep out any emboli from above. If,
after suturing the vessel, the circulation is not restored through the
limb search should be made for an embolus at some other point.

He reports 8 cases of embolectomy and 11 others done by other
Norwegian or Swedish surgeons. The outcome was successful in 10.
In the total 45 cases, the operation followed within twenty-four hours
in 43 and the outcome was favorable in 11.

Emboli and Embolic Gangrene. Bull,3 in a total of 6140 necropsies,
found evidence of embolism in the arm or leg in 15, but in 4 per cent
of the total cadavers he found thrombosis in the aorta in 9 cases, and
in the heart in 234. He concludes that embolism in a limb is usually
merely one link in a chain of emboli in other organs, prior to; simul-
taneous with, or subsequent to, the embolism in the extremity. In
his 15 cases of the latter embolism was manifest in the lungs (9), in
kidneys (9), in spleen (7), in brain (4) and in the intestines (1) in all
but one of the cadavers of this group. Among the 237 cases with
thrombosis in the heart, embolism was found in all but 48. _ In 113
it was in the lungs; in 74 in the kidneys; in 60 in the spleen; in 32 in
the brain; in 6 in the intestines; and also the 15 with embolism in the
limbs; and the 1 case of embolism in the liver.

1 Archivio Italiane de Chirurgia, Bologna, April, 1922, No. 2, vol. 5.

2 Acta Chirurgica Scandinavica, Stockholm, January 17, 1922, No. 4, vol. 54.

3 Ibid.

248 LEE: SURGERY OF THE EXTREMITIES

Blood Transfusion in Severe Burns of Infants and Young Children. Bruce
Robertson1 accepts the pathologic explanation of shock in burns that
is now being generally accepted, and which Lee and Furness presented
in 1918. The primary shock, resulting from pain and undue radiation
of the body heat, corresponds to primary wound shock encountered in
all traumatism, depending upon the amount of dead tissue produced;
a secondary or toxic wound shock appears in from twelve to twenty-
four hours and the toxins of the burned tissues are thrown into the blood
stream. This action decreases after three or four days if the patient
survives. Robertson has been administering blood transfusion and in
more serious cases bleeding followed by blood transfusion, and a series
of 100 consecutive cases is discussed.

The Choice of Methods of Blood Transfusion.2 In the early days of
its modern clinical application blood transfusion was an exceedingly
difficult procedure, involving an artery to vein operation with refined
surgical technic. Gradually, the mode of introducing blood from
donor to recipient has been simplified until at present the transfer
can be carried out with far greater ease. Syringe and cannula methods
have come into vogue and made transfusion easier, and hence available
for many physicians instead of a few specialists. Of late the device
of adding citrate to render blood incoagulable and keep it in this state
for hours, so that it can be injected into patients at will, has been given
favorable consideration in many quarters. The relatively simple pro-
cedure of citrate transfusion has been widely employed since the World
War, and is today perhaps the method of election for most practitioners
in most cases.

Those who are experienced in the work of blood transfusion realize
that it is by no means an uncomplicated therapeutic measure. Objec-
tionable reactions are experienced by many patients subjected to trans-
fusion, and sometimes the results are so grave that the best of opera-
tors are seriously disturbed by the outlook. A few months ago Bern-
heim3 announced that, as a rule, in from 20 to 40 per cent of all citrate
transfusions a reaction of greater or lesser severity will occur despite
the various precautions that study of the technic has made imperative.
On the other hand, after the more refined whole blood transfusions, the
percentage of reactions is scarcely as high as 5.

These are facts which cannot be ignored, despite the operative diffi-
culties presented in many cases by the demand for transfusion of
unmodified blood. Unger4 has recently substantiated the difference
between the two methods of transfusion referred to with respect to
the frequency of chills, febrile reactions and evidences of shock. His
investigations at the College of Physicians and Surgeons, New York,
indicate that the unfavorable action of the anticoagulant sodium citrate
is exerted directly in the cellular elements of the blood. As early as
1919 Drinker and Brittingham,5 of the Peter Bent Brigham Hospital,

1 Canadian Medical Association Journal, October, 1921, 11, 744.

2 Editorial, Journal of the American Medical Association, No. 7, vol. 78.

3 Journal of the American Medical Association, July 23, 1921, 77, 275.

4 Ibid., December 31, 1921, 77, 2107.

5 Archives of Internal Medicine, February, 1919, 23, 133.

THE <lloi<h: OF METHODS OF BLOOD TRANSFUSION 249

Boston, came to the conclusion that titration seems to harm red cells,
and possible direct evidence of this exists in the occasional promotion
of fragility by the citrate. The indication is that hemolysis contributes
a certain number of reactions, although it is too slight to he detected
by direct methods. A further cause of the objectionable reactions
following transfusion of titrated blood has been sought in changes
demonstrably occurring in the blood platelets after titration.

Unger has further contended that citrate not only affects the vvd blood
cells so as to render them more fragile, but also alters some of the
immunologic properties of the blood. Tims, it decreases the avail-
able quantity of complement, a vital factor in the defence of the organ-
ism against pathogenic microorganisms, in two ways: By its direct
action on complement itself, and by introducing into plasma an anti-
complementary substance which inactivates complement. This sub-
stance is derived directly from the bodies of red blood cells. According
to Unger, sodium citrate also reduces almost to nil the function of
opsonins, and practically destroys the phagocytic power of white blood
cells.

Obviously, these newer facts present the shortcomings of transfusion
with titrated blood in a light that further discloses unsuspected advan-
tages in the use of unmodified blood from the biologic standpoint.
The time has perhaps arrived when it is desirable to consider not only
gross incompatabilities between the bloods of donors and recipients, as
is now done in a routine way to avoid post-transfusion agglutination
or hemolysis, but also the finer qualitative differences. Unger main-
tains that since complement and the phagocytic power are of prime
importance in the protective action against pathogenic organisms,
unmodified blood from a donor wTith high phagocytic index should be
employed when attempting to combat local or general infections by
means of transfusion.

The use of titrated blood has been attended with too many benefi-
cent results, especially in emergency situations, to be summarily
discarded for a procedure admittedly calling for professional skill not
attained by most practitioners. It is generally known that the giving
of whole blood requires constant practice and knowledge of surgical
technic; hence this method of transfusion doubtless must remain in
the hands of surgeons. The problem of the physician therefore con-
sists in the ability to determine when the more difficult procedure is
imperative. For diseases, Unger concludes, in which the transfer of
blood is indicated for itself, that is, when it is required as a tissue— as
in various anemias, blood diseases and infections— there can be no
question as to the superiority of whole unmodified blood. In cases of
hemorrhage, on the other hand, when the purpose is not so much to
replace pathologic with normal blood as it is to replenish the impover-
ished circulation or to bring about cessation of hemorrhage, citrated
blood may serve as a substitute. Here, as so often in practical medi-
cine, the judgment of the physician must determine what course is most
conducive to human welfare.

250 LEE: SURGERY OF THE EXTREMITIES

Factors in Reactions After Blood Transfusions. Butsch and Ash by1
report T.'w transfusions studied to find an explanation of the reaction.
The sodium citrate method, used routinely in the Mayo Clinic, was
employed, and a uniform technic was carried out.

The cause of reactions was approached from the points of technic,
the factors intrinsic to the patient and the factors involving both the
patient and the donor.

The omission of saline solution caused no decrease in the number of
reactions. The washing of all utensils in strictly neutral water caused
no improvement in the percentage of reactions. Neither did the treat-
ment of new rubber tubing recommended by Stokes and Busman give
results to indicate that such tubing had been an important factor
in transfusion reactions. Desensitization of the patient was attempted
by protracting the transfusion time to thirty minutes. In 4 patients
thus treated, there were 2 severe reactions.

Certain points regarding the condition of the patient were then
observed. It was found that the tendency to reaction was least when
the initial temperature was normal and increased with an increase in
the initial temperature. In 2(3.5 cases the hemoglobin percentages
showed a definite relation to transfusion reactions, the lower percentages
giving the greater number of reactions. This agrees with the reviewer's
experience.

Types of Cases Unsuited for Citrated Blood. Bernheim2 publishes the
following warning from his experience, that there are apparently two
types of cases which should not be given citrated blood :

1. Cases in which there has been a hemorrhage of such intensity
that the extreme limits of bleeding have been reached, and the patient
is in such a state of shock that everything in the nature of additional
shock must be avoided.

2. Those states of anemia, either primary or secondary, in which
the blood depletion has progressed to such limits that the patient is
almost dead.

Length of Life of Transfused Erythrocytes. Red blood corpuscles from
donors in Group 4 transfused into patients in Group 2 with pernicious
anemia secondary to nephritis, Wearn, Warren and Ames3 found,
remained in the circulation longer than has been generally believed to
be the case. The last of the transfused red blood cells disappeared
from the circulation in from fifty-nine to one hundred and thirteen
days, with an average of eighty-three days. No difference was noted
in a series of observations in the duration of the stay of the transfused
red blood corpuscles in the circulation between patients with primary
anemia and secondary anemia (due to nephritis).

Reinfusion of Extravasated Blood. Rietz4 induced intra-abdominal
hemorrhage on 7 dogs and then restored the extravasated blood to the
blood stream. The intervals ranged from fifteen minutes to nineteen

1 New York Medical Journal, 1921, 113, 513.

2 Journal of the American Medical Association, July 23, 1922.

3 Archives of Internal Medicine, April, 1922, No. 4, vol. 29.

4 Lyon Chirurgical, January, 1922, No. 1.

INTRAVENOUS USE OF ACACIA 251

hours. A form of soft coagulation occurred and the balance of the
extravasated blood was so defibrinated that it did not coagulate on
on standing even for a week, or even when coagulating substances are
added to it. The clots formed were small and soft, and contained
relatively few blood corpuscles, showing the process differs somewhat
from ordinary coagulation. The fluid blood has the aspect of normal
blood, but its character is that of defibrinated blood, and thus it is
adapted for infusion. This defibrination, Rietz suggests, is probably
caused by the respiratory and peristaltic movements in the abdomen.
The erythrocytes kept their normal color and shape for nineteen hours
at least. Two of the dogs died after autotransfusion of blood before
defibrination had occurred. Rietz accepts this explanation of the fatal
outcome. Coagulation had not occurred, but was on the point of
occurring, and it did occur after the extravasated blood had been
infused, disturbing the colloidal balance in the blood stream, with fatal
results. To avoid this, the extravasated blood must be examined and
not used until coagulation no longer occurs. To insure greater safety,
he advises citrating the blood to about 0.4 per 1000, and straining the
blood through filter paper or a double-gauze compress. The risks of
this autotransfusion seems to be greater the more intense the anemia.

Goder1 has compiled 52 cases, in which the extravasated blood was
infused, with recovery in all but 1 of the otherwise practically mori-
bund patients. He reports a favorable case from his own experience,
and commends the procedure as harmless and life-saving. Tubal
abortion is generally the indication, but it has been applied with rupture
of the spleen, of the liver, and gunshot wound of the spleen and of the
lung.

Zimmerman2 states that, from his experimental and clinical research,
the peritoneum is able to resorb extravasated blood freely, and thus
the erythrocytes and other elements in fluid blood in the absence of
infection may return unharmed into the blood. We have referred
to Sweet's similar statement last year. He advises, therefore, with a
ruptured tubal pregnancy to clear out the clots, and leave to the natural
forces the resorption of the fluid blood. This occurs so rapidly that the
erythrocytes reach the blood in a still functionally capable condition.
Only when the pulse is too weak and growing weaker, is it best, as
a last resource, to retransfuse the blood to hasten matters.

Lohnberg3 advocates the complete removal of extravasated blood,
and reports 14 cases, in which he reinfused the extravasated blood,
injecting this between 500 and 1150 cc of blood. It was infused, still
warm, after defibrination by stirring with a glass rod, using a glass
cylinder, tube and porcelain funnel and filtering through eight layers
of mull.

Intravenous Use of Acacia.4 The discussion by Bayliss,5 the originator
of the intravenous use of acacia solution, will be appreciated by readers,

1 Deutsch. Ztschr. f. Chir., April, 1922, Nos. 5-6, vol. 170.

2 Ztschr. f. Geburtsh. u. Gynak., November 12, 1921, No. 2, vol. 84.
8 Ibid.

4 Editorial, Journal of the American Medical Association, No. 10, 78, 730.

5 Journal of the American Medical Association, No. 24, 78.

252 LEE: SURGERY OF THE EXTREMITIES

although it is disappointing to learn that the main issues raised by the
editorial, to which he replies, are not effectively disposed of by him,
but are virtually left in statu quo. It is now generally accepted that
acacia has a limited and uncertain usefulness, notwithstanding the
impression conveyed by the author that the place of this substance in
therapeutic armamentarium is assured, and that the mechanism of its
action and other features are settled. That this is far from being the
case can be readily ascertained from the papers quoted in the editorial
and those on the mechanism of its action and usefulness recently pub-
lished by Zondek1 and Meyer.2 Bearing in mind the accidents from
the use of acacia that have been reported, the lack of agreement as
to its beneficial effects, among surgeons who have tried it, the experi-
mental evidence that has been reported as to its deleterious effects, and
the paucity of data indicating its clinical usefulness, conservative prac-
titioners will still withhold their verdict. Moreover, the questions of
intravenous therapy, which are involved in any discussion on the use
of acacia in shock, hemorrhage and allied conditions, are an important
and serious complicating consideration.

Lee3 reports sudden death in 2 patients following intravenous injec-
tion of acacia.

Taken as a whole, the results obtained following the injection of
acacia in these 2 patients give the impression that this agent is not
entirely harmless.

Whether emboli, or thrombi, and agglutinated corpuscles occurred
in these patients is not known. It would be useless to speculate further,
but the dangers of intravenous medication are emphasized again, and
these are not confined to acacia, whose role as a beneficial therapeutic
agent in shock, hemorrhage and allied conditions, may, indeed, be
questioned.

Intramuscular Administration of Sodium Citrate (A New Method for
the Control of Bleeding). Upon the clinical application of the anti-
coagulating action of sodium citrate to blood transfusion, in 1915,
there immediately arose the question of the effect of sodium citrate on
the coagulability of the recipient's blood. Would the introduction of
sodium citrate, recognized as an anticoagulant, result in a suspension of
coagulation in the recipient? That this did not occur was soon estab-
lished; in fact, a transient shortening of the coagulation time in the
recipient, with a subsequent return to the previous level, was found to
follow the transfusion of citrated blood. In an effort to seek an ex-
planation for this paradoxical action, some experiments were begun by
Neuhof, in 1916, and again taken up, in 1919, by Neuhof and Hirshfeld.4

Summary. 1. The administration of sodium citrate intramuscularly
intravenously and subcutaneously, results in prompt and pronounced
shortening of coagulation and bleeding time. This is a hitherto unrecog-
nized pharmacologic action of the drug.

1 Biochem. Ztschr., 1921, 116, 246.

2 Klin. Wchnschr., 1922, 1, 1.

3 Journal of the American Medical Association, August 26, 1922, No. 9, vol. 79.

4 Annals of Surgery, July, 1922, No. 1, vol. 76.

MYOSITIS 253

2. The shortened coagulation time is of two to three hours' duration,
with gradual return to the normal within twenty-four to forty-eight
hours.

3. The sodium citrate curve occurs not only in individuals with
normal coagulation and bleeding time, but also in those in whom there
is a pathologic prolongation, notably in jaundice.

4. It does not occur in blood disease characterized by blood platelet
deficiency — hemophilia and purpura. These diseases appear to com-
prise the sole contraindications to the use of sodium citrate for the
control of bleeding.

5. The dose for intramuscular administration of sodium citrate is
9 gm. for adults. A 30 per cent solution is used, 15 cc in each buttock,
preceded by novocaine. The intramuscular method is free from danger,
no untoward results having been noted in 200 cases, and is therefore
the method of choice.

Myositis Ossificans. Last year we reviewed an article by Painter
on this subject. Three cases in our hospital work during the year and
a fourth reported by Kessel1 as "osteophytic ankylosis of the elbow"
justify another reference to the subject.

Painter2 found 339 cases. Any muscle may be affected, the most
common being the brachialis anticus, quadriceps extensor, abductor
longus and biceps of the upper arm, in this order. The authors believed
such deposits to be caused in various ways, the majority being pro-
duced by osteogenesis of avulsed periosteum, which, when it has escaped
into the muscles enveloping the bone from which the periosteum has
been torn, continues to grow. A progressive type of the disease
occurs in the young and extends through practically all the striated
muscles of the body. A tendency to revert to an osseous condition
by retrograde metaplastic reaction, inflammatory or katabolic, may
explain ossification in muscle in individuals who have just enough
of a tendency toward that type of katabolic transformation to react
to the stimulus of a violent trauma. Other individuals have neither
the progressive nor traumatic type, but, under slight, oft-repeated
trauma, develop transformation in tendon sheaths and fascial attach-
ments of certain muscles. A diathesis or dyscrasia, in varying degree,
may underlie all types.

Our cases all involved the brachialis anticus and, after excision of the
process, perfect functional results were obtained.

Kessel's case followed a trauma; it was diagnosed as a fracture, and
treated for two or three months by massage and passive motion. The
roentgen ray then taken (Fig. 16) was not diagnosed as myositis ossificans.

Myositis. From the results of an investigation of 28 cases of myositis
at the Mayo Clinic and the findings in animals given injections of cultures
made from material obtained, Rosenow and Ashby3 conclude that myo-
sitis, including even the mild, transient affections of muscles, is caused

1 Annals of Surgery, 1922, p. 638.

2 Boston Medical and Surgical Journal, July 14, 1921, 165, 45.

3 Focal Infection and Elective Localization in the Etiology of Myositis, Archives
of Internal Medicine, 1921, 28, 274.

254

LEE: SURGERY OF THE EXTREMITIES

in the main by lodgment and growth of bacteria, usually streptococci,
which have elective affinity for muscle tissue.

Fig. 16.— Osteophyte producing ankylosis of elbow. (Kessel.)

The cases of myositis investigated fell into three distinct clinical
groups: (1) Cases of acute and chronic myositis, without other demon-

Fig. 17.— Osteophyte removed freeing joint. (Kessel.)

strable lesions at the time of study; (2) cases with predominating symp-
toms of myositis, in which periarthritis and arthritis were present; and

REPAIR OF PERIPHERAL NERVES 255

(3) cases in which myositis was the chief factor, hut there was associated
neuritis or perineuritis.

Cultures from these three groups were injected intravenously into
rabbits and the resulting lesions tabulated. In the first group were 90
animals, in the second 61 and in the third 51. Of the first group of
animals, 88 per cent had muscle lesions, l(i per cent were found to have
turbid joint fluid, and only f per cent had lesions in the nerves. In the
second group the corresponding figures were 79 per cent, 28 per cent
and 0 per cent, while in the third group they were 67 per cent, 8 per
cent and 35 per cent. These results paralleled very closely the findings
in the clinical cases, not only with regard to muscular lesions, hut also
with regard to the incidence of lesions in the joints in the arthritis group
and in the nerves in the neuritis group.

The lesions were usually found between muscle fibers and, in the
earlier lesions, extravasation of red blood cells, dilatation of adjacent
capillaries, and edema, with loss of striation of the muscle fiber as the
swelling increased, were the chief characteristics. Later, in larger
lesions, fragmentation and necrosis of the muscle fibers occurred as
leukocytic and other cells became numerous. Of 11 animals given
injections of cultures of streptococci which had been killed with liquor
formaldehyde, 8 showed lesions of the muscles. This indicates that
the property of localization is resident within the bacterial cell.

Pathogenesis of Dupuytren's Contraction of the Palmar Fascia. Byford1
reports 705 cases of Dupuytren's contraction recorded in literature, in
addition to 38 personal cases. In these 38 cases, 5 showed a possible
etiologic factor in a local condition; 4 had an injury or strain of one
hand from six months to two years before the onset of the contraction.
The injured cases were 13.4 per cent, too small a proportion for a
probable etiology. Twenty-three cases were associated with rheuma-
tism, and only 7 had constitutional disease. In Nichols' series of
cases, Dupuytren's contraction and rheumatism were associated in
84 per cent, and in the writer's series in 60 per cent. The physical
examination of the cases here reported showed them to have about
the same physical defects as other people of their age and occupation.
However, one very marked condition was noted, the almost universal
disease of their teeth. Rheumatism is now quite generally considered
to be due to focal infection. The association of rheumatism with
Dupuytren's contraction in from 60 to 84 per cent of the cases makes
it evident that a focal infection is at least quite commonly present in
the latter condition. A source of infection was present in 97.3 per
cent of cases, the most common location being the teeth. All foci of
infection should be removed to prevent progression of the contraction.
A period of six months should elapse between the removal of these foci
and the treatment of the contraction itself, which is, of course, surgical.

Repair of Peripheral Nerves.2 With the publication of the observa-
tions of Miller3 and Malone,4 the rationale of the surgical treatment of

1 Medical Record, September 17, 1921, 100, 487.

2 Editorial, Journal of the American Medical Association, February 25, 1922,
No. 8, vol. 78.

3 Archives of Surgery, January, 1921, 2, 167. 4 Ibid, November, 1921, 3, 634.

25G LEE: SURGERY OF THE EXTREMITIES

injuries to peripheral nerves seems to be complete. Miller correlates
the microscopic changes in the process of nerve regeneration with the
gross changes and with the restoration of the tensile strength of the
nerve at the point of suture, showing that, at the end of the fourth week,
physical and physiologic healing alike are complete. Malone shows
the practical application of the laws of reflex action to the determina-
tion of the presence or absence of conducting neurons at any point
in the course of the regenerating nerve distal to the line of suture,
demonstrating that the fact of physiologic healing in any sensory or
mixed nerve may be proved by the elicitation of reflex respiratory stimu-
lation on the application of a threshold stimulus at any point on the
nerve trunk distal to the line of suture to or beyond which the axons
have penetrated.

For many years it has been admitted that the first steps in the regen-
eration of peripheral nerves following section appeared as the prolifera-
tion of the nuclei of the neurilemma, with the formation of protoplasmic
bands in the proximal and the peripheral segments of the divided nerve ;
but whether the neuraxis was of central origin or whether it might be
formed complete in the peripheral segment and await only union with
a similar element in the proximal segment to become a fully functioning
nerve tract offered a field for debate. In 1912, Ransom1 convincingly
demonstrated the origin of the protoplasmic bands from the prolifera-
tion and growth of the cells of the neurilemma and the bridging of
the suture line in a divided nerve by them. He further showed that
the new axis cylinders appear on the eighth day as side branches above
the zone of degeneration in the proximal stump, and travel distant
across the gap and down the peripheral stump guided by the proto-
plasmic bands. Kirk and Lewis2 observed similar phenomena after
tubulizing with fascia a gap formed by the removal of a 10-mm.
(f-inch) segment of the sciatic nerve in dogs. They demonstrated
that the protoplasmic bands which form bridged the gap within six
days, and that the regenerated neuraxes from the proximal stump
penetrate the distal segment within three weeks.

Huber, in 1919, called attention to the importance of the anatomic
structure of the nerve trunk and to the nerve pattern. The nerve
trunk he likened to a conduit system, each tube of the system leading
to some definite point. In the regeneration of nerve fibers the proto-
plasmic bands, supported by the endoneurium, are comparable to the
empty tubes of such a conduit system, some leading to motor end-plates,
some to sensory end-organs. If the distal segment of the nerve were
rotated so that the patterns of the distal and proximal segments no
longer coincided, then motor nerves might find their way down sensory
pathways, and sensory nerves might find their way to motor organs,
and thus be as effectually lost as though they had never been regenerated.
The demonstration that individual nerve fibers may not always occupy
the same relative position in the nerve trunk, but may interweave with
other fibers, to a certain extent need not deprive the nerve pattern

1 Journal of Comparative Neurology, 1912, 22, 187.

2 Bulletin of the Johns Hopkins Hospital, February, 1917, 28, 71.

R EPAIR OF I' E RIPHERAL A E /,' 1 ES 257

idea of significance from the practical standpoint, although the longer
the .segment to l>c replaced, the more unlikely it appears that the proxi-
mal and distal nerve patterns in the unrotated segments would coin-
cide. Also, the importance of the conception of the protoplasmic
bands in the role of a conduit system remains unshaken.

Clinically, the advances in the technic of nerve suture have been so
great as to render obsolete most of the time-honored methods of nerve-
grafting and of tubulization of nerve defects by fascia, formalized veins
and other ingenious, but highly uncertain, artifices. Today, with very
few exceptions, defects in nerve trunks may be repaired by direct end-
to-end suture, with reasonably bright prospects of success. This has
been made possible by the development of five aids to the approxima-
tion of the ends of a divided nerve. Briefly, these methods are:

(1) Mobilization of the nerve by open dissection for considerable dis-
tances above and below the point of suture; much more may be gained
in this manner by stretching the nerve without first dissecting it free.

(2) Adduction, or extension of limbs, as may be indicated in order to
relax the nerve trunk. (3) Flexion of joints, as the elbow and wrist,
in lesions of the nerve trunks of the forearm. (4) Transposition of
nerve trunks to shorter routes. (5) A two-stage operation; at the
first sitting, the fibrous ends of the divided nerve are approximated as
closely as possible, by means of the proper application of the four
devices mentioned above, and sutured. During the succeeding wTeeks
the nerve is stretched by permitting gradual extension and abduction
of the limbs so that at the second sitting it may be possible to obtain
direct approximation of the nerve segments after proper excision of
the impervious fibrous end-bulbs. Naffzinger1 estimates that by the
proper combination of methods, gaps of 10 cm. (4 inches) or more in
the chief nerve trunks of the extremities may be successfully bridged
and end-to-end suture obtained.

End-results of Nerve-grafting in Surgery of Nerve Wounds.
During the last three years we have devoted considerable space to the
subject of surgery of the peripheral nerves because of the unusual
amount of material which has resulted from the Great War. It is,
therefore, opportune, to report the various end-results which are now
appearing in literature.

Gosset and Charrier2 classify their results as follows : Good, if sensory
and motor regeneration has occurred; mediocre, if there are only signs
of sensory return with slight motor or electric reaction; and poor, if
there is no evidence of regeneration. They agree with most reports,
that the results obtained by direct end-to-end suture are better than
those obtained by nerve-grafting. However, they do report an unusual
percentage of good results obtained by nerve-grafting, of which auto-
grafting is the best. Of the autograft operations performed by the
authors, 35 per cent gave good results, 45 per cent mediocre results, and
20 per cent poor results. Of 2 heterograft operations performed by
them, both were failures. These results compare with the reports of

1 Surgery, Gynecology and Obstetrics, March, 1921, 32, 193.
- Jour, de Chir., 1922, 19, 1.

258 LEE: SURGERY OF THE EXTREMITIES

other surgeons, except that they found the reports of 2 successful
heterografts performed by French surgeons. These reports are the
most favorable we have encountered in the surgery of the peripheral
nerve.

Studies in Reduction of Bone Density. Phemister1 says that reduction
in the density of bone may be local, regional or general— according to
the cause. In bone infections there are four processes by which reduc-
tion in density may be produced: (1) There is destruction of dead bone
at the seat of greatest inflammatory activity; (2) there is local destruc-
tion of living bone or caries; (3) there is rarefying osteitis in the neighbor-
ing living bone for variable distances about the area of complete bone
destruction; (4) there is regional atrophy of disease. In osteomyelitis
bone necrosis results from the effect of the toxins in the most severely
inflamed region. The unossified elements of the dead bone are rapidly
killed by toxins and removed by the action of the serum and leuko-
cytes. The calcareous deposits are only removed as a reparative
process by the absorptive action of the granulations. From six to fifteen
days elapse before signs of reduction in density can be shown by the
roentgen ray. Tuberculosis usually produces localized osteitis. The
metaphyseal region of the end of the bone is more frequently involved
primarily, especially during the first decade. After the tenth year,
primary foci in the epiphyses are seen with increasing frequency.
Ingrowth of tubercular granulation tissue beneath the articular cartilage
is a common occurrence leading to destruction of the articular cortex
of bone and to disappearance of the sharp line which it normally casts
in roentgen rays. Bone syphilis produces gummatous caries in irregu-
larly distributed and various-sized areas. Shadows from new bone
formation are frequently interspersed. In bone tumors reduction of
density results almost entirely from breaking-down of living bone by
cellular activity. In metastatic carcinoma of bones the relative amounts
of bone destruction and new bone formation bear some relation to the
seat of the primary tumor and its degree of malignancy and rate of
growth.

Metastatic carcinoma of the breast tends to produce bone destruction
with little associated new bone formation, while carcinoma of the pros-
tate produces little bone destruction and much new bone formation.
Reduction in density in sarcoma usually occurs en masse, and, while
the outline of the area of destruction may be irregular, extensive pocket
formation is uncommon. New bone formation in the ossifying types of
sarcoma may be sufficiently extensive to offset the reduction in density
resulting from bone destruction, but its distribution and arrangement
are usually such that the shadows cast are of diagnostic significance.
Central giant-celled tumors affecting the ends of the living bones form
a special group, and it is questioned whether they should be classified
with sarcomas. They reduce bone density by eccentric growth and are
entirely devoid of any tendency to undergo ossification. The reduc-
tion of density in bone cysts is quite similar to that in giant-celled

1 American Journal of Roentgenology, 1921, 8, 355.

BONE-GRAFTING 259

tumors in that the process begins in the interior of the bone and produces
eccentric erosion without subsequent ossification of the tissue which
caused the erosion. Small perforations of the cortex are more common.
The site affected is farther from the bone end.

Bone-grafting. McWilliams' makes some comparisons of the various
methods of bone-grafting based upon 1390 cases that he has been able
to analyze. These do not include Albee's statistics, which he says were
not available. There are three requirements of a successful bone
graft: (1) It must bridge a defect; (2) it must be of a size and type to
reestablish circulation; (3) it must act as a stimulus to osteogenesis.
Raw living bone is a very powerful stimulus of this kind and the
osteoperiosteal grafts offer a very large area of raw bone and hence are
to be preferred to all other methods of grafting.

There is much in osteogenesis that is still unknown, namely, the
chemistry and physiology of the process. Why a bone graft will some-
times melt away in the tissues and be absorbed and its place not taken
by new bone we cannot explain. It is one of the most disappointing
results of a well-conceived and well-carried-out bone-graft procedure,
and it happens to every one and occurs in all methods.

From these 1390 bone-graftings he finds:

1. That there was a total of 82.3 per cent of successes, with 17.6
per cent failures.

2. In the order of successes, we have:

(a) With bone pegs, 95.8 per cent were successful.

(b) With the osteoperiosteal method (Delageniere), 87.3 per cent

successful.

cent were successful.

(d) With the inlay method, 80.9 per cent wrere successful.

(e) With the intramedullary method (Murphy), 75.6 per cent

were successful.
(/) With the combined intramedullary (at one end) and the
inlay (at the other), 60 per cent were successful.

3. The presence or absence of periosteum seems to exert no influence
on the success of bone grafts. Proportionately, the percentage of suc-
cesses without periosteum (82.3 per cent) is the same as with (82.9
per cent). In the end-to-end method there were 18 per cent more
successes than failures without periosteum, and in the inlay method
9 per cent more successes without periosteum than with; wrhile, on the
contrary, with the intramedullary method there wrere 13 per cent more
successes with grafts writh periosteum than without. It is difficult to
explain the cause of the differences in the various methods.

4. Suppuration occurred in 121 cases, or 8 per cent; 32 per cent of
these succeeded. Suppuration is the most frequent cause of non-
success of graftings, with insufficient immobilization and too short
duration as the second most frequent cause.

5. The conclusion is reached that the most successful method of bone-

1 Transactions of the American Surgical Association, 1921, 39, 600.

260 LEE: SURGERY OF THE EXTREMITIES

grafting is by the osteoperiosteal method (Delageniere). The bony
defect should be filled in with small bone chips, and on the overlapping
ends of the fragments covering in the bone chips should be placed one
or two strips of periosteum with adherent osseous plaques taken from
another bone. This method is as applicable to large as to small bony
defects.

6. The cause of many non-successes is due to defective immobiliza-
tion or to undue curtailment of its length. From four to six months'
immobilization is ordinarily required for complete success.

7. There is sufficient evidence to prove that the most effectual treat-
ment of non-union of fractures is bone-grafting.

8. The causes of failures of bone-graftings, summarized, are:

(a) Improper method of grafting.

(b) Suppuration.

time.
(77) Fracture and dislocation of the grafts.
(e) Atrophy of the ends of the bone to be grafted.

9. The intramedullary method of grafting should be discarded.
Fractures. In a very interesting way Scudder1 discusses certain

problems in the treatment of fractures of bones. Though pertinent
they are not new, and he quotes Hippocrates' writing in 400 B. c. "I
know physicians who have the reputation of being skilled in giving
the proper positions to the arm and binding it up after fracture, while
in reality they are only showing their ignorance. But many other things
in our art are judged of in this manner for people rather admire what is
new, although they do not know whether it is proper or not, than what
they are accustomed to and know already to be proper; and what is
strange, they prefer to what is obvious."

Under the term fracture of bone Scudder includes:

Fracture of the skull, protector of the brain.

Fracture of the spine, so adequately shielding the cord from injury.

Fracture of the thorax, with possible damage to the contained pleura,
lung and heart.

Fracture of the pelvis, containing abdominal organs sometimes
seriously damaged.

Fracture of the long and short bones of the upper and lower extremi-
ties.

Fracture of the articular surfaces of all joints.

Gunshot fractures of the skeleton.

Open or compound fracture, potentially infected wounds.

All dislocations.

It will not be forgotten that associated with these fractures there
may be contused and lacerated wounds, and there may be sprains of
joints distant from the apparent injury. Shock may be present, slight
or serious. In addition, damage to muscles, to single nerves or nerve
plexuses, to tendons and to important bloodvessels may complicate the
situation.

1 Transactions of the American Surgical Association, 1921, 39, 580.

FRACTURES L'lil

There arc certain problems necessarily included in this group of
injuries which are not altogether settled, viz.:

(a) The process of repair of fractures.

(b) The causes of ununited fractures.

(e) The proper handling of crushed fractures.
(/) The treatment of malunited fractures.

General surgeons, as a group, are not interested in treating fractures.
There are, of course, exceptions in every community, but the average
man has been attracted to the more dramatic fields of abdominal sur-
gery. As a consequence, at the present time, the collective results of
fracture treatment throughout this country are deplorably poor. The
community itself, every fracture patient, and the working man in par-
ticular, are all asking for better results. The employer of labor is
demanding that injured men be returned to work more quickly and that
fewer hours be lost.

To meet these demands, Scudder has definite suggestions:

1. The organization of a fracture service in each of the large hospitals
of the country. This should consist in:

(a) Special wards.

(6) A special fracture personnel consisting of a chief, who should be
a surgeon of broad general experience, and with him should be assist-
ants and the whole service should be continuous throughout the year.

(c) This continuous control should include the out-patient service,
where the ambulatory cases are received and treated, and the policies
of the out-patient and house-fractures service should be identical and
under the same personnel.

(d) The emergency wrard or accident service, insofar as fractures are
concerned, should likewise be under the direct care of the chief of this
service. A fracture should be considered as much of an emergency as is
a case of perforated gastric ulcer. The initial treatment is vital to a
satisfactory outcome in both instances.

2. Adequate instruction of the undergraduate medical students.

3. By instituting smaller hospital units in towns adjacent to and
remote from large centers. The equipping of such hospitals with
adequate apparatus and the instruction of certain interested physi-
cians or surgeons of the community in the care of fractures by indi-
vidual surgeons from the larger centers.

4. Graduate instruction of the general practitioner interested in
fractures .

5. By encouraging the specialization within general surgery of the
surgery of fractures.

6. The organization of a clinical surgical fracture society.

The report of the Committee1 on Fractures of the American Surgical
Association has very definite suggestions upon this subject, and we
quote at length.

1 Transactions of the American Surgical Association, 1921, vol. 39.

262 LEE: SURGERY OF THE EXTREMITIES

The Committee finds:

1. The results are best in the age period under fifteen years. Con-
servative treatment is generally effectual during this period.

2. Good anatomic restitution of a fractured long bone results in the
best functional results and has the shortest period of disability.

3. While comparatively few open operations are reported under the
fifteen-year age period, it seems to make little difference in the result,
except in senile cases (where it is unfavorable), what the age period is
when the operation is done.

4. The end-results of non-operative and operative treatment of com-
pound fractures show very little difference in the anatomic result, but
the functional results are better after operative treatment, except in
compound fractures of the shafts of both bones of the leg; here the
reverse seems to be true.

5. The average period of disability (that is, the time lost from work)
in fractures is as follows:

SIMPLE FRACTURES.

For fractures of the shaft of the humerus .
For fractures of the head and neck of humerus
For fractures of the condyles of the humerus .
For fractures of the shaft of both bones of forearm
For fractures of the femur, all sites, adult cases
For fractures of the femur, all sites, children .
For fractures of the leg, all sites

14.0 weeks
11.5 "
9.0 "
10.9 "

8.2 months
4.5 ^ "
4.7 "

(Periods of disability were not recorded accurately in many of the reported cases
and very seldom in compound fractures.)

COMPOUND FRACTURES.

For fractures of the femur 11.0 months

For fractures of the leg 7.0 "

For fractures of the upper extremity 4.0 "

6. For good functional results the humerus should show not more
than 1 cm. shortening and no appreciable angulation. No pain or
paralysis should result.

The forearm bones should show no shortening; function should always
be good and no lasting pain result.

Fractures of the shaft of the femur should not result in shortening
greater than 2 cm., nor in a fixed position of angulation or rotation.
The function of all joints should be good.

Fractures of the shaft of the bones of the leg should result in no
appreciable shortening and no angulation or rotation. All function of
the joints should be preserved.

7. There is no method or splint universally applicable; all depends
upon the discrimination of the surgeon and the manner in which the
apparatus is applied and maintained.

The late war has brought into prominence the suspension-traction
method for treating fractures. The Balkan frame or the Hodgen
splint for suspension is used, and tongs or the Steinmann nail are used

FRACTURES 263

for traction directly on the distal fragments. The Thomas splint has
proved of great value in the treatment of fractures of the shaft of the
femur; it is recommended especially when hospital treatment cannot
be obtained.

Plaster casts and molded splints are indicated and are useful only
after a fracture has been satisfactorily reduced.

Recommendations. 1. The Committee recommends, as a general
principle, that fractures be treated by a skilled surgeon.

2. Roentgen-ray pictures should be made by a competent roent-
genographer and a rluoroscope should be used for diagnostic purposes
and for guidance in applying the permanent dressing. At least two
roentgenograms should be taken, and they should be taken from oppo-
site perpendicular directions. Roentgenograms should also be taken
after permanent dressings are applied, to prove proper reduction, and
at the end of treatment to show the results of the union and for the
purpose of a graphic record.

:!. Fracture should be reduced immediately after the injury if it is
possible to obtain and apply proper retaining apparatus or splints.
The statistics show markedly better results when the treatment is
begun at once. It is, however, not only useless, but cruel to subject
the patient to the pain of manipulation for reduction unless the surgeon
has proper fixation apparatus at hand and the subject is where he may
have a permanent dressing applied.

4. General anesthesia should be employed, as a rule, to facilitate
reduction and to prevent pain, unless the condition of the patient
contraindicates it.

5. Neither the non-operative nor the operative methods is to be
recommended exclusively. Each has its indications and should be
employed when required. Generally speaking, the age period under
fifteen years is the period in which non-operative methods are especially
effectual.

6. The open method when adopted should be employed early. It
may be used at any age period, except in senile cases, whenever a
roentgenogram shows a deformity or a position of the fragments, which
obviously cannot be reduced or when proper efforts at reduction and
retention have proved unavailing.

7. Some form of rigid plate applied directly to the bone seems to
be the best fixation method in operative cases.

8. Open operations for simple fractures should be undertaken only
by experienced surgeons, who are thoroughly equipped by training,
and who have proper instruments and apparatus to meet all the possible
indications of the operation.

9. After fracture of the long bones of the lower extremity some
efficient form of caliper should be used when the patient begins to
walk, and should be continued for some weeks in order to prevent
yielding of the newly united fragments to the weight of the body and
the production of bending and distortion at the seat of fracture.

10. The treatment of any fracture ought not to be considered com-
plete until full restitution of functions has been secured. For this

204 LEE: SURGERY OF THE EXTREMITIES

purpose every hospital which treats fractures should be equipped with
apparatus for mechanic, electric and hydropathic treatment. The
reconstructive treatment should be considered in every case an essen-
tial part of the general treatment. Also, in order to make the record
of every case of major fracture complete, a careful follow-up system
should be adopted and sedulously followed.

11. The work of this committee has been greatly hampered by the
inadequacy of the records submitted for its consideration. A large
proportion of the cases had to be rejected entirely, and most of them
were so incomplete as to make deductions based upon them misleading.

The first step in the betterment of practice is the study of results
achieved by present-day methods. An adequate study is impossible
without complete records.

Fractures of Transverse Processes of the Lumbar Vertebrae.
Davis1 claims that fractures of the transverse processes of the lumbar
vertebra3 are not infrequent injuries, but have been frequently over-
looked. With modern improvement of our roentgen-ray technic, aided
by the use of duplitized films, intensifying screens, and especially the
Potter-Bucky diaphragm, many cases formerly diagnosed "sprained
back" "malingering," etc., are now found to be fractures of the trans-
verse processes.

In reviewing the literature on this subject, there seems to be con-
siderable difference of opinion as to the factor in causing the fracture.
Some observers (Hartwell,2 Roberts and Kelly3 and others) state that
the process fractures result almost invariably from direct trauma.
PeQuervain,4 Treves5 and others say that the injury may result from
direct or indirect violence. Stimson6 states that fractures of the trans-
verse processes occur in combination with other fractures, but are
rare, except in such cases, and that in the few instances in which fract-
ure has occurred alone, it is the result of gunshot injury. Rhys7 states
that these fractures are developmental in origin, adding that fractures
occur in the absence of injury in almost all cases, and that the first
lumbar is the most frequently affected.

The muscle, in which we are most interested in considering trans-
verse process fractures in the lumbar region, is the quadratus lumborum.
It is irregularly quadrilateral in shape and broader below than above.
It arises by aponeurotic fibers from the iliolumbar ligament and the
adjacent portion of the iliac crest for about 5 cm., and is inserted into
the lower border of the last rib for about half its length and by small
tendons into the apices of the transverse processes of the lumbar
vertebra?.

The action of the quadratus lumborum muscle is to draw down the
last rib and it acts as a muscle of inspiration by helping to fix the origin
of the diaphragm. If the thorax and vertebral column are fixed, it

1 Surgery, Gynecology and Obstetrics, 1921, No. 33, 3, 272.

2 Colorado Medicine, April, 1919. 3 Fractures, p. 219.

4 Clinical Surgical Diagnosis, p. 535. 5 Applied Anatomy, p. 657.

6 Fractures and Dislocations, p. 150.

7 British Medical Journal, May 24, 1918.

FRACTURES 265

may act upon the pelvis, raising it toward its own side when only one
muscle is put in action, and when both muscles act together, either from
below or above, they flex the trunk.

Now if the thorax, spine and pelvis are all three fixed and a force is
applied to the muscle, it is evident that something must give, and a
fracture of the transverse process, a separation of a lumbar rib, or a
separation of the twelfth rib, or a combination of these, results. That
is by indirect violence. And it is the writer's opinion that practically
all of these fractures occur in this manner.

If the patient is under twenty-five years of age it is possible that the
secondary ossific centers present a locus minoris resistentice at their
union with the primary ossific centers of the transverse process.

The symptomatology of these injuries is definite. Pain in the back;
"backache" is the chief symptom. The pain is well localized, con-
stant and does not radiate. It is exaggerated by any motion that
changes the line of the weight of the body. Rising from the recum-
bent to the sitting position and from the sitting to the erect position
increases the pain. In no position other than lying relaxed in bed
is the patient free from pain. Flexion and hyperextension of the
spine, and lateral bending, both toward and from the injured side,
cause pain. Bending toward the injured side sometimes causes more
pain than bending from the injured side.

Roentgen-ray examinations of these cases may show a linear fracture
with the fragment in good position. More often, however, there is
considerable diastasis of the fragments. If there is a lumbar rib this
may be seen dislocated from its articulation with the spine, or the same
may be true of the twelfth rib.

Oudard1 gives short histories of 7 unpublished cases of isolated
fractures of the transverse processes of the lumbar vertebrae, 5 of
which were cases of his own. In the literature he has found the reports
of :!1 cases published since the first case was described by Kalthoener
in 1891. As a rule, only one process is fractured. Multiple fractures
are exceptional.

Fracture of Bones of Forearm. In a report of the Committee of
the American Surgical Association, 1921, Martin and Eliason2 state that
non-operative treatment gave good functional results in 78 per cent,
as compared with 68 per cent operative, and showed only 2 per cent
bad functional results as compared to 13 per cent bad functional results
in operative cases. The cases operated upon were in the main those in
which injury was most extensive and delay in adequate treatment most
pronounced.

Reduction of Fractures of the Lower End of the Radius.
Jopson3 employs general anesthesia for all reductions of Colles's fracture
He uses a wedge-shaped wooden block, covered with a towel, on which
the patient's arm is rested, flexor surface down. An assistant holds
the arm so that the supporting block comes just above the lower end

1 Bull, et mem. Soc. de chir. de Paris, 1921, 17, 706.

2 Transactions of the American Surgical Association, 1921, 39, 519.

3 International Clinics, 1921, Series 31, 3, 250.

266 LEE: SURGERY OF THE EXTREMITIES

of the upper fragment. This gives fixation and leverage for the surgeon,
who grasps the hand and wrist below the fracture and pursues the
usual maneuvers, namely, overextension (to release the fragment), for-
ward and downward traction and flexion of the wrist. The displace-
ment is thoroughly reduced and even slightly overcorrected. A padded
splint is applied until a secure callus is formed. The fingers are left
free and frequent dressings and massage are practised. The period
of splint support is varied according to the type of the fracture.

Fracture of the Scaihoid Bone (Wrist). Saner1 reports 3 cases
of fracture of the scaphoid bone. The immediate signs and symptoms
are sharp pain, followed by swelling of the wrist-joint, and all move-
ments, especially extension, are painful. On palpation, the joint is
tender, the area of greatest tenderness being immediately distal to the
lower end of the radius on the posterior aspect of the joint. The
history of a fall on the hand and somewhat thickened, weak and pain-
ful wrist with very restricted movements, is almost diagnostic of an
old-standing injury to a carpal bone, most commonly the scaphoid.
In all cases two or more articular surfaces are involved. Owing to the
small size of the fragments, they atrophy rapidly; on this account, and
often also on account of lack of treatment in the early stages, it may be
said that fracture of the scaphoid is the rule, rather than the excep-
tion. When seen early the forearm and hand are splinted, with the
wrist slightly extended. Massage is begun during the first week, as
well as some active movements of the fingers, but the wrrist should be
kept immobilized for at least three weeks. There is no guarantee,
even with the best care, that union will occur and the prognosis is
always doubtful. In late cases, with non-union, it may be worth while
excising the scaphoid. The end-results of excision of the scaphoid
vary with the length of time that elapses between the injury and the
operation, in other words, to what extent arthritic changes have devel-
oped. The operation cannot restore a wrist to normal; its main object
is to alleviate pain and thus give a greater freedom of use, especially
in the power to grip, and consequently increased strength. In some
cases removal of the scaphoid gives increased movement, while in others
there is no alteration.

Mechanics of Reduction in the Treatment of Spiral Fract-
ures. In a discussion of this subject, Rixford2 includes only those
fractures which are typical spiral fractures and are the result of torsion.
The frequency of this type of fracture has not been realized in the
past. Thus, Stimson, in 1912, says they are rare, and Scudder, in
1911, does not mention them. Zuppinger estimates that 26 per cent
of all fractures of the tibia are spiral, and that 39 per cent of all fract-
ures of the shaft of the tibia are of this type, and Rixford feels that these
figures are probably low.

The average results of treatment of this type of fracture are unsatis-
factory, both anatomically and functionally. Non-union is frequent in
spiral fractures of the lower third, and irregularity of the bone is a rule,

1 Practitioner, London, November, 1921, 107, 367.

2 Transactions of the American Surgical Association, 1921, 39, 589.

FRACTURES 267

even when union takes place and there is nearly always an external
rotation of the lower fragment, with a frequent anterior flexion deform-
ity and more or less shortening. In addition, there is frequently
abduction which is, at times, of sufficient degree, especially when
associated with external rotation, to be the cause of breaking down
of the arch of the foot and a resulting pronation and flat foot.

Spiral fractures of the shaft of the long bone are the result of torsion.
The fundamental principles determining the direction of the spiral
and the pitch were worked out by Zuppinger.1

In practice we find that other forces are active besides torsion at
the moment of the fracture and afterward. This is especially true of
the lower extremities where weight-bearing, augmented in its effect
by momentum in running and jumping, adds an important element
of longitudinal thrust. If this thrust is active after the spiral fracture
is complete, it will then cause the fragments to pass by each other and
the periosteum on the side of the vertical component of the fracture,
not being torn apart, will be stripped from one or both pointed ends of
the fragments and remain as a periosteal bridge. Thus, clinically, we
usually find the tips of the fragments in spiral fractures denuded of
their periosteum. The fragments under these circumstances are so
free to move in any direction that their sharp projecting points and
knife-like edges may lacerate muscles, nerves, bloodvessels, neighboring
joints and often perforate the skin, making the fracture compound.
These long points of the fragments may also be broken off by the
bending of the limb at the point of fracture.

From the above considerations, and the complicated form of the
spiral fracture, it is evident that if the fracture is not perfectly reduced
there is practically no reduction at all. The untorn periosteal bridge,
being attached along the sides of the bone more or less opposite to the
spiral component of fracture, is very short, and it usually effectually
prevents the correction of rotary displacement and is one of the reasons
for the common clinical experience of the persistence of external rota-
tion after union of a spiral fracture.

Rixford believes that, from a practical point of view, spiral fractures
of the long bones are never reduced except in open operation. While
not an advocate of the open treatment of fractures in general, or even
in any very large proportion of cases, he is convinced that in his experi-
ence early operative reduction and fixation of spiral fractures of the
long bones have given far better results than traction and external
fixation. In the choice of operative or non-operative treatment, Rix-
ford insists that the mechanic problems involved and the anatomic
displacements resulting in this type of fracture so predispose to mal-
union that it is never justifiable to wait until this condition of mal-
union develops before operating and he submits that, barring definite
contraindications to operations in general, all spiral fractures of the
long bones in adults and adolescents, and some in children, be managed
by open early operation.

1 Beitr. z. klin. Chir., 1906, 52, 391; 1909, 64, 562.

268 LEE: SURGERY OF THE EXTREMITIES

The technic he suggests is as follows: 1. Determine the location
and form of the fracture by roentgen-ray studies, and locate that part
of the spiral portion which is opposite the longitudinal component.

2. Cut down on this spiral part of the fracture and remove all detached
chips of bone and any larger fragments if they are not required as a
part of the splintage and drill both fragments, if possible, with a mini-
mum disturbance of their position, in a line obliquely to the spiral that
will most effectively resist torsion displacement. In general, this line
will be transverse to the axis of the bone.

3. Pass a stout silver wire through the drill holes.

4. Reduce the fracture by traction, rotation and leverage. Draw
the wire taught and then hammer the ends down into the bone.

5. Close the wound and apply fixation apparatus, such as a Thomas
splint or plaster of Paris.

6. Remove the fixation appliance frequently to permit of massage,
mobilization of the joint, and electric development of the muscles and
arrange for the patient to make functional use at the earliest possible
moment.

We can agree to most of this report, but take exception to his use
of silver wire and drill holes for internal fixation. In our experience
the Parham band has been easier to apply, causes less injury to the bone
and has remained in the tissues wTith less disturbance than any other
form of foreign body. Nor can we agree with his statement that all
spiral fractures should be treated by open operation. Excellent func-
tional results, one might almost say perfect functional results, can be
obtained in spiral fractures of the tibia when treated with skeletal
traction.

Caldwell1 also regards open operation as the best in spiral fractures
and advocates the use of the band.

He advocates the removal of the band in twTo or three months. Most
of his cases have refused to accept this advice, and this has been our
experience for we have not been able to remove but one of ours, because
of the absence of symptoms and the refusal of the patient.

Suspension-traction Treatment of Fractures of the Long
Bones Near Large Joints. Each year we have devoted so much
space to the subject of the suspension-traction treatment of the fractures
of the long bones that it is with some hesitancy that we again refer to
the subject. In the past our references have been largely due to the
experiences, personal sometimes, of military surgeons, and this year
the literature contains a number of reports of its use in civil surgery.

Hartwell2 contributes a report that should be carefully studied by
every surgeon. He reviews the underlying principles, which make
for efficiency in the suspension-traction treatment of fractures of the
long bones.

We appreciate Hartwell 's emphasis that the application of these
principles is often beset with difficulty and that patient and untiring
effort alone wall be rewarded with success. It is a method that can

1 Annals of Surgery, June, 1922, No. 6, vol. 75.

2 Transactions of the American Surgical Association, 1921, 39, (512.

FRACTURES

269

be applied only after considerable experience and with attention to
detail that many surgeons are unwilling to give. lie might have said
that it was a method that was laboriously taught to a very large num-
ber of young surgeons during their military service, both abroad and in
this country, but if one was compelled to judge of its value by its gen-
eral use in the civilian hospitals by these men at the present time, we
would soon hear very little about it. As an inspector of hospitals, one

Fig. 18 Fig. 19

Fig. 18.— Spiral fracture of tibia. Fracture of fibula as usual does not show
in roentgenogram taken of tibial fracture, but the shortening of one-half to three-
fourths inch indicated by radiogram is proof that the fibula is broken at some
point. (Caldwell.)

Fig. 19.— Roentgenogram taken same time as Fig. 18, showing fracture of fibula
just below knee. (Caldwell.)

of our greatest disappointments has been to find that the younger
surgeons have not persevered in this line of treatment. It may be
that it is not alone the difficulties of the method itself, but the added
difficulties of introducing it into the surgical services of older and
more conservative men, and the universal disinclination on the part
of the administrative departments of all hospitals to try anything new
that requires the investment of money. This is the excuse which we

270

LEE: SURGERY OF THE EXTREMITIES

ourselves are compelled to offer, and to read such a report as Hartwell
is able to give of what he has accomplished at Bellevue should encour-
age everyone to make a similar effort, but its greater value is that it

Fig. 20.— Roentgenogram taken after band was applied. No splint was applied,
but leg was laid in a wire basket for ten days. In eight weeks band was removed,
at which time patient was walking comfortably. (Caldwell.)

Fig. 21.— Instrument to facilitate Parham-Martin band about bone. (Caldwell.)

is a complete demonstration which we can offer to our various hospital
organizations.

Hartwell states that every fracture in his service is made an emerg-
ency case. That statement itself is sufficient as a text for a course of

FRACTURES 271

lectures in the surgical care of fractures. At a recent conference of
the American ( 'ollege of Surgeons <>n the subject of fractures, it was the
consensus of opinion that probably the greatest factor in the present
unnecessary disability, resulting from improper care of this class of
injuries, was the primary treatment. This primary treatment, of
necessity, must be entrusted to the hospital interns; usually the ambu-
lance or accident-ward man, who, in the majority of eases, is the young-
est intern in the hospital. This is a matter of hospital administration
and easily corrected if the necessity is appreciated of placing all emerg-
ency treatment in charge of the senior house officer. But this lack
of appreciation of the gravity of fractures does not begin with the
hospital organization, but in the medical schools themselves, and there
are very few men at the present time who are taught that every fract-
ure case should be considered a major surgical emergency, and that
its treatment should be undertaken immediately on admission.

In the cases which he reports, though he lays no particular stress
upon it, we would like to emphasize as the third important point in
his paper, namely, that the patients are not allowed to walk until
fitted with a caliper splint, and that the braces are not removed until
after wearing them for six months.

Jones has called attention to this in his report of the end-results of
fractures of the femur caused by gunshot wounds. The orthopedists
have long realized the necessity of supporting fractured bones wTith
adequate braces until they become sufficiently rigid to hold the body
weight without bending. It has, howrever, been our experience that
it is one of the most difficult innovations in hospital practice to persuade
the surgeons and the patients of the necessity of this prolonged bracing.

Fractures of the Leg Bones Involving the Ankle. In spite
of all the classic writings of Pott, Dupuytren and others, there is no
entirely satisfactory classification of ankle fractures. Pott described a
fracture which does not exist, and Dupuytren commended him for his
acute observation. A transverse fracture of the fibula 3 inches from
the low^er end, as described by Pott, is not found in any series of
roentgenograms or postmortem specimens. Quenu states that the
French mean by "Dupuytren's fracture" exactly what the English
mean by "Pott's fracture." It is probable that this fracture is the
common one first described accurately by Maisonneuve.

Ashhurst and Bromer1 state that in the production of fractures of
the ankle, rotation of the foot around the long axis of the leg play an
important part. Inward rotation is almost inseparable from a move-
ment of adduction and the foot is quite mobile in this direction. In
outward rotation, however, the foot acts as a rigid lever. In relation
to the tibia, this is a lever of the first class, wTith the fulcrum at the
anterior border of the fibula, the power arm being the anterior four-
fifths, and the weight arm the posterior one-fifth, of the distance from
the posterior border of the ankle to the toes. With relation to the
fibula, however, it is a lever of the second class, writh the fulcrum at

1 Archives of Surgery, 1922, 4, 51.

272 LEE: SURGERY OF THE EXTREMITIES

the posterior border of the inner malleolus, and the power arm the
entire distance from the posterior ankle border to the toes. The longer
power exerts more force against the external malleolus than the shorter
power arm exerts against the internal malleolus. The lower end of
the fibula is thus fractured by a force which pries the malleoli apart.
Of all fractures at the ankle, this oblique one of the lower end of the
fibula is the most frequent (25 per cent). If the rotation goes far
enough the tip of the internal malleolus is broken off. In their series
of 300 cases, this type of rotation fracture, including all its complica-
tions and variations, occurred 100 times. In 4 cases the force against
the internal malleolus was great enough to fracture the entire lower
end of the tibia.

Forced abduction produces in most cases an isolated fracture of the
internal malleolus. In their series 6.5 per cent were of this type. If the
tibio-fibular ligaments hold, the fibula may be caused to break through
its malleolus by the direct force of the abduction, but never above these
ligaments by bending. A bending fracture occurs only when the tibio-
fibular ligaments have ruptured; one end of the bone must be free and
the other end fixed. In 30 cases of fracture of the surgical neck of the
fibula, the lesion showed the characteristics of fracture by bending in
28, and if it was not accompanied by rupture of the tibio-fibular liga-
ments there was a history of direct violence or clinical evidence of
severe sprain of these ligaments.

Not infrequently the posterior marginal fragment of the tibia is a
distinct clinical entity. It was described by Cooper, in 1820, but, in
1915, Cotton described it as a "new type of ankle fracture," and by
some writers it is referred to as "Cotton's fracture." The fragment
varies from a small portion of the posterior lip to a large piece extend-
ing 10 cm. up the shaft, and there may be posterior displacement of the
foot. The mechanism which produces it is a crushing force from below
upward. This type of fracture occurred in 58 of the 300 cases reviewed.
Forced adduction may cause splitting of the inner part of the tibial
shaft, but the more common lesion is a tearing off of the external malleo-
lus followed by a crushing fracture of the inner malleolus.

The three abnormal movements of external rotation, abduction and
adduction are responsible for about 95 per cent of ankle fractures.
It is impossible to classify these fractures anatomically because the
variations in many instances are due only to variation in the force
which produces them. The authors, therefore, offer a classification
based on the mechanism of the fracture.

On the basis of a roentgen-ray study of the ankle-joint, Bromer
warns that in making a diagnosis of fracture of the posterior lip of the
tibial-articular surface, one should remember that a supernumerary
bone, the os trigonum, is sometimes present at this point. With
regard to the diagnosis of tibio-fibular diastasis by the roentgen ray, the
authors state that if the space between the lateral margin of the fibula
and the lateral border of the anterior tibial tubercle exceeds more than
two-thirds of the width of the fibula, it is most probably that there is
diastasis of the first degree. Emphasis is placed on standardized accur-

FRACTURES 273

ate technic in roentgenography. Gross lesions are easily recognized

by almost any method, but to attain the finer points in diagnosis an
exact method of technic is necessary.

Fracture of the Neck of the Femur. Whitman's method of
traction, abduction and inward rotation of the limb and immobiliza-
tion in a plaster cast is receiving more and more favorable comment
each year. Ridlon1 advocates this method, as do many others, but he
very timely calls attention to a study which he has made of results of
fracture of the neck of the femur during the past twenty-nine years,
and in which there were many cases in which practically no treatment
whatever had been given and excellent results had been obtained.
This does not mean that he advocates non-treatment, but it does more
than raise the question that good results are sometimes due as much
to the natural tendency of fractures to heal as to any peculiar treatment
they may receive.

Galloway,2 writing upon the same subject, divides his cases of fract-
ure of the neck of the femur into several groups. The first includes
persons of advanced age, poor general physical condition and low
resistance. In such cases the saving of life is the essential object, and
the treatment of the fracture should be secondary. We entirely agree
with this statement and feel that in some of the present enthusiasm
for newer methods of treatment this is entirely overlooked, and the
mortality in this group has been unnecessarily increased as a result,
The second group includes patients who recover rapidly from the first
shock of the accident and whose physical condition permits maximum
treatment of the fracture. To this type of case Galloway applies the
Whitman cast, as is general at the present time.

Fractures of the Cotyloid Cavity by Enforcement and Central
Luxation of the Femur. Although these lesions are generally taught
separately, a study of 53 cases in the literature and 1 personal observa-
tion has led Delannoy3 to consider them as different degrees of the same
condition.

The first case of this condition was reported by Ambrose Pare in 1788.
Before the general use of roentgen rays the diagnosis was often difficult,
and many cases went undiagnosed. The injury is rare before the tenth
year, probably because of elasticity of the bone, while most cases have
occurred between thirty and forty. The causes are, in the order of
frequency: (1) A fall on the hip; (2) on the feet; (3) on the shoulder.
The line of force must be directed in such a way that the femoral head
strikes directly against the thinnest part of the acetabulum, which is
the postero-inferior portion. Mild abduction is the most favorable
position of the limb. A fall upon the feet is often followed by a fall
on the trochanters, so that it is not always possible to say which caused
the injury. Marked abduction, however, brings the femoral head down-
ward so that a fracture is more likely to occur. A few isolated cases
due to falls on the shoulder have been reported.

1 Journal of the American Medical Association, 1921, 77, 1815.

2 Surgery, Gynecology and Obstetrics, 1921, 33, 692.
:t Key. de chir., Paris', May, 1921, 40, 317.

274

LEE: SURGERY OF THE EXTREMITIES

Fractures of the acetabulum without central dislocation of the head
of the femur are very rare, so that it seems as if the displacement was
primary and not a secondary occurrence from muscular pull. The
lines of fracture are most often vertical, horizontal or star shaped. In
fractures of the bursting type the displacement is slight since the inner
pelvic muscles and the periosteum hold the fragments in place.

Fig. 22.— Case 1 (from above and behind). Huge broadening of heel, with the
peroneal plate shoved up squarely against the external malleolus. White dotted
line shows roughly the amount of bone removed at operation. (Cotton.)

Fractures of the Os Calcis. Cotton,1 in a very interesting way,
calls attention to the uncommon fracture of the os calcis, which is rarely
seen except as the result of industrial accidents and is followed by a
large percentage of cripples, and these cripples are usually strong men
in their youth or vigorous middle age. There are, of course, a few
1 Transactions of the American Surgical Association, 1921, 39, 752.

FRACTURES 275

cases of this type of fracture that recover with a fairly good functional
result, but they are cases in which there is very little displacement.
A very large proportion, probably more than half, are partly disabled
and permanently handicapped in their work, and Cotton says that
one-third are totally disabled for real work. His article upon the
treatment of recent fractures of the OS calcis has been reviewed by us,
and this paper is devoted to the consideration of old fractures. As a
result of his method of impaction by lateral blows Cotton says he has
not had any of his cases result in permanent disability. While he sees
fewer recent cases each year, of late he is having referred to him more
and more cripples who have been untreated or mistreated for this type
of fracture. The os calcis is foreshortened, and flattened. This
shortening beyond the loss of the "spring" results in little disability.
Occasionally, there is a sharp outward deviation of the whole heel,
resulting inevitably in flat feet, which cannot be relieved by support.
Spurs on the plantar surface of the os calcis are not uncommon. The
loss of some part of the lateral motion is a constant disability, and loss
of all lateral motion is not rare. This limited motion is painful and
disabling because of the resultant clumsiness. This loss of motion
results from what Cotton calls a clogging of the posterior calcaneo-
astragaloid joint, either from fracture across it, or from fracture dis-
placing the unbroken joint surfaces or shortening the slide; or from new
bone heaped up about the malleolus.

"He advises correcting these causes of disability by operative measures.

Posterior Dislocation of the Foot. T. Turner Thomas1 reports a
series of 8 cases of this posterior dislocation of the foot, which we
have reviewed during the last two years. It is a deformity which is
far more common than is generally appreciated, and its improper treat-
ment, or lack of treatment, inevitably results in an unnecessary and
crippling disability. We reviewed a case that we had encountered
last year and refer again to the subject in order to impress it upon
general surgeons. It has long been held that there is a decided
tendency in Pott's fracture for the foot to slip backward and some-
times so far that the body of the astragalus lies entirely behind the
tibia. There is a roentgen-ray plate showing such a displacement in
Stewart's Manual of Surgery. Quenu was probably the first to call
attention to the fact that a posterior dislocation of the foot indicates
the presence of a fracture of the posterior marginal surface of the tibia,
as is shown in so many of Thomas' cases. Though it may occur without
a posterior marginal fracture of the tibia, this probably is very rare.
Thomas believes that this posterior marginal fracture of the tibia and
the posterior dislocation of the foot are due to a force driving the foot
upward and backward. Under general anesthesia he has obtained
reduction by: (1) Traction on the foot, then forcible dorsal flexion, and
(2) abduction or adduction, according to which, was necessary for the
correction of the lateral deviation. Overcorrection is not likely to
occur, but undercorrection is frequent. Tenotomy of the tendon of

1 Surgery, Gynecology and Obstetrics, July, 1922, No. 1, 35, 98.

276

LEE: SURGERY OF THE EXTREMITIES

Achilles was performed in both cases reported by Downs and the
reviewer, and, as a result, the correction of the deformity was very
easily accomplished. Thomas concludes that:

Fig. 23. — The cases represented here by 1, 2, 3, 4 and 5, show in each instance,
the lateral and antero-posterior views before and after the reduction of the displace-
ments. In 6 we have both these views after reduction only, because none was taken
before reduction. In 7 the patient refused to permit reduction and in 8 the antero-
posterior views taken before and after reduction were lost. (Thomas.)

1 . The posterior dislocation of the ankle, with fracture of the posterior
tibial margin in Pott's fracture, has received little attention in this
country. The dislocation has been generally attributed to relaxation
of the ankle-joint, resulting from Pott's fracture.

DIAGNOSIS OF BONE AM) .JOIST LESIONS BY ROENTGEN RAY 277

2. The prognosis will depend largely upon the degree to which the
reduction of the displacement has been accomplished and maintained
during the development of bony union. Without reduction, the impair-
ment of function must he serious. With reduction, the function has
been essentially normal in all of his reduced cases, with the exception
of the 2 recent ones which have not had sufficient time to recover.

3. The reduction should always be proven with the roentgen ray, and
it should be maintained by a plaster cast because no other method
would maintain the reduction satisfactorily. Moreover, for the same
reason, the cast should not be removed until bony union is assured.

Delayed and Non-union of Fractures. J. A. Nutter1 speaks of
delayed union from the sixth to the twelfth month and non-union after
the twelfth month. General statistics seem to agree upon non-union
in 2 to 3 per cent of cases, and that certain bones and certain localities
are more predisposed to delayed and non-union, as the humerus between
the middle and upper thirds, the femur at the middle third and the neck,
and the tibia and fibula in their lower third. He makes the interest-
ing observation that a substantial proportion of cases of delayed and
non-union seen at the Bucks ton Hospital were found to be syphilitic,
and to respond to antisyphilitic treatment.

This has been our personal experience in a surprising number of cases
in the general surgical wards of several hospitals, and it is now a stand-
ing order that a Wassermann reaction be made at the time of admission
upon every case with a fracture. We are certain that the unnecessary
loss in hospital days, when this condition is overlooked, has been pre-
vented in our hospital work by this routine procedure.

We also agree with his statement that general causes, such as nephritis
and diseases of the ductless glands, are theoretical rather than practical.
The local causes, although less numerous, are of greater importance.
Interposition of soft tissues, incomplete immobilization, sepsis of
virulence and duration sufficient to cause necrosis and sequestration,
the use of metallic plates and screws, resulting in osteoporosis at the
fragmentic ends. His treatment for delayed union is conservative.
Baking, massage, hydrotherapy and the physiologic stimulus of func-
tion hastens union, especially in the lower limbs. For non-union in
aseptic cases, he prefers bone-grafting.

Diagnosis of Bone and Joint Lesions by the Roentgen Ray. Baetjer2
states that there are three age periods of bone: (1) The growing period,
from one to twenty years; (2) the period of maximal health, from twenty
to forty years; and (3) the period of decline, after forty years. Differ-
ent lesions affect different age periods. Injuries to bone are according
to the age of the bone. Take, for instance, the hip; in the first period
fracture occurs at the epiphysis, which is the weakest part. In the
second period the epiphysis is united to the neck of the femur and
synovial membrane; the synovial membrane slips. In the third period,
the bone is more brittle, owing to absorption of calcium salts, and

1 Journal of Bone and Joint Surgery, 1922, 4, 104.

2 Report of the Meeting of the Medical Society of the State of New York, April,
1922, Journal of the American Medical Association.

278 LEE: SURGERY OF THE EXTREMITIES

fracture of the neck of the femur occurs. In childhood the bones are
much more flexible and green-stick fractures occur. In older people
long, oblique fractures occur. In the elderly and aged, comminuted
transverse fractures occur.

Disease of the bone is also in relation to age periods. The origin of
the lesion is important. By determination of the origin, certain lesions
can be ruled out. Bone lesions in children show three age periods:
From one to three years, from three to six years and from six to fourteen
years. In the first period the common diseases are scurvy, syphilis
and rickets. From three to six years, tuberculous lesions of the joints
are common. From six to fourteen years, Perthes's disease is often
seen. There are also laws relating to sex: From one to five years, lesions
are as common in girls as in boys. After six years, boys play more
dangerous games and suffer a higher proportion of fractures. In men,
the heavier trades show a larger percentage of bone lesions. After
fifty years, the two sexes again become equal in this respect. In regard
to neoplasms, carcinomatous metastases are more common in the
female, following carcinoma of the breast. The most common cause
of bone cancer in the male is carcinoma of the prostate, metastasizing
into the pelvis and lumbar spine.

Extra-articular Tuberculosis of the Posterior Surface of the Patellar
Apex. Jean1 states that primary tuberculosis of the patella has been
recognized for a long time, and more than 100 cases are found in the
literature since 1888. The relative rarity of the condition is probably
due to the slight vascularization of the bone. In the child an abscess
tends to develop outside of the joint on the anterior surface of the bone;
in the adult it tends to develop on the posterior surface. The author
reports 2 cases. Both patients were adults, and in both the tubercular
process developed on the posterior surface of the patellar apex. In the
adult about one-fifth of the posterior surface of the patella in the region
of the apex is connected with the anterior bursa of the joint and is,
therefore, extra-articular. In the child under fourteen years of age the
whole posterior surface is covered with cartilage. This explains the
difference in the direction in which the abscess develops. Both of the
author's cases were operated upon. In 1 case the patellar tendon was
freed by lateral incisions and turned back, the osteitic areas in the
posterior surface of the patella being curetted.

Tuberculosis of the Bone. Allison2 reports a study of 50 cases of bone
and joint tuberculosis. All cases in which there was any doubt regard-
ing the diagnosis were eliminated. The localization of the infection
was as follows: Spine, 3 cases; hip, 8; knee, 16; shoulders, 6; ankle and
tarsus, .">; wrist, 1; elbow, 2; trochanter major, 1; trochanter minor, 1;
tibia, 2; ulna, 1; humerus, 1; sternum, 1; malar bone, 1; rib, 1. The
atypical localization in several cases might surprise one who had the
conventional idea that the disease occurs only at certain points.

In most of the cases studied the joints were involved, and in every
case there was involvement of bone. Allison believes that the disease

1 Rev. d'orthop., 1921, 3d s. 8, 393.

2 Archives of Surgery, 1921, 2, 593.

GROWTH OSTEOMYELITIS OF ADOLESCENT LONG BONES 279

is primarily a disease of the bone. Although it is n<>t certain where
the original infection occurred in all of the eases reviewed, it is certain

that the hone became the chief seat of the process. No evidence was
found of primary synovial involvement, and no ease of pure tubercu-
lous synovitis. There was abundant evidence, however, to show that
a primary focus in the bone progresses to the joint and extra-articular
tissues.

It is confusing to describe bone tuberculosis and joint tuberculosis
separately. Both are the same process, the variations being due to the
character of the tissues infected. The author suggests that, in teaching,
the occurrence of tuberculosis in the shafts of bones be given more
attention than is usually devoted to it.

The Problem of Growth Osteomyelitis of Adolescent Long Bones. Speed
and Kellogg1 point out that one of the serious and unfortunate results
of acute osteomyelitis of adolescent bones is in the disturbance of their
growth. Our knowledge of the bone growth at the present time rests
upon very definite experimental work. Bidder,2 by inserting needles
into the epiphyseal cartilage plate of the long bones of dogs, found that
which ever side of the cartilage plate was injured ceased growing. If
the whole width of the cartilage plate was damaged, there was uniform
hindrance of the longitudinal growth, the injured cartilage plate being
replaced after such injury by connective tissue or bony trabecular
Oilier, Haab, Vogt3 demonstrated experimentally that mechanical
stimulation of the diaphysis near the epiphyseal cartilage plate increased
the length of the bone. A temporary separation of the epiphysis and
immediate replacement did not interfere with the growth, but when
the cartilage plate was completely excised the growth of the bone
stopped at once. Haas4 further demonstrated that the normal longi-
tudinal growth of bone is also dependent upon sufficient blood supply
to the region of the epiphyseal cartilage plate. This experimental
evidence warrants our accepting the principle that the most important
elements necessary for the longitudinal growth of bone are located in
columns of cartilage of the epiphyseal plate and that (a) the nearer
the injury comes to the cartilage columns, the greater is the growth
disturbance; (b) there is also relation between the degree of destruc-
tion of cartilage columns and the loss of growth; (c) that disturbances
of direct blood supply of the epiphyseal cartilage plate also have a
marked hindering effect on the longitudinal growth of bone.

Acute inflammation of the bone, arising primarily in the epiphyseal
area or spreading secondarily by continuity from the diaphysis, may
cause destruction of the cartilage plate. The neighboring and imme-
diate bloodvessels become blocked with thrombi and the epiphyseal
arteries disappear. Less severe grades of infection, as exemplified by
Schlatter's disease and Perth's disease, may cause complete or partial
death of the cartilage plate without formation of pus, but the vascular

1 Surgery, Gynecology and Obstetrics, April, 1922, No. 4, 34, 469.

2 Arch. i. exper. Path. u. Pharm., 1873, 1, 248.

3 Arch. klin. Chir., 1878, 22, 343.

4 American Journal of Orthopedic Surgery, 1917, 15, 157, 305, 563.

280

LEE: SURGERY OF THE EXTREMITIES

supply may suffer just as much when the lesion resolves by round-cell
infiltration and final fibrous tissue replacement. In these cases bone
may grow across the epiphyseal area when the power of growth is com-
pletely obliterated. When the young growing epiphysis is thus de-
stroyed and the action is rapid, the end-result after a few weeks is com-
parable to a mechanical destruction or excision of the cartilage plate.
There will follow, therefore, all the phenomena occurring after experi-
mental destruction or excision of the plate or destruction of its blood
supply, namely, stoppage or uneven growth, depending upon the degree
of obliteration. When the part involved concerns the limb containing
but one bone, the loss of length may be compensated by skeletal read-
justments and by extra growth of the remaining epiphysis in that
bone. Where one bone of a pair, as in the forearm or the leg, ceases to
grow from one of its epiphyses the uninterrupted growth of the other
bone produces a deformity, the slower growing bone being pushed to
one side.

Fig. 24 Fig. 25

Fig. 24. — Osteomyelitis of the lower end of the tibia following open fracture and
resulting in stoppage of growth of the lower, least important tibial epiphysis. Note
the fibula continues to grow and is causing a bowing deformity of the leg. The
osteomyelitic focus is quiet and apparently healed.

Fig. 25. —Lateral view of the same leg as in Fig. 24, a slight drop foot is present.
(Speed)

The three clinical conditions which produce the greatest destruction
of the cartilaginous plate, by actual destruction or interference with
its blood supply, are: (1) Fracture (epiphyseal separation); (2) inflam-
mation (osteomyelitis or epiphysitis) ; (3) operative removal of a carti-
lage.

The practical application of these principles to the surgery of osteo-
myelitis in adolescent long bones Speed summarizes as follows:

1. Early operation on osteomyelitis of the shaft of long bone before

GROWTH OSTEOMYELITIS OF ADOLESCENT LONG BONES 281

the epiphyseal areas become involved or their vessel thrombosed and
obliterated. In the experience of the reviewer this cannot be too
strongly emphasized. Radical operation and drainage of the medullary
cavity in osteomyelitis is practically never performed early enough,
even at the present time.

2. Extreme conservatism in draining acute suppurative epiphysitis
of adolescent long hone. Very wisely Speed has explained this state-
ment, which does not mean that we should be conservative in performing
the operation of drainage, but that the operation should be conservative
in its removal of the cartilaginous plate. Thus, he says that the peri-
osteum should be opened by means of one longitudinal incision, and
should not be reflected any more than necessary. That a sharp curette
should never be used in the epiphyseal area, granulations being wiped
out with gauze. He advocates the immobilization of the limb by
splints and the application of traction in extension to prevent pathologic
dislocation and permit of efficient drainage.

3. The parents should be warned of the possibility of growth inter-
ference and encouraged to have the patient frequently examined with
roentgen ray after healing has taken place.

4. If the growth seems arrested, suitable splints or apparatus should
be applied to prevent deformities while waiting for the growth to
recommence. In the leg this means especially a provision against
early weight-bearing without proper caliper support. From our ex-
perience, this is the most common error in the postoperative treatment
of osteomyelitis at the present time. Over and over again cases are
referred with a disabling deformity, resulting from lack of supportive
splints* after a perfect surgical operation upon acute or chronic osteo-
myelitis. The orthopedists undoubtedly sin less frequently in this way
than the general surgeon, and if the general surgeon attempts the
surgical treatment of osteomyelitis he certainly opens himself to severe
criticism if he does not give as much attention to the postoperative
care as to the operation itself.

5. The skin over the growing ends of the healthy companion bone
should be carefully protected so that pressure sores will not develop.

6. Remember the law of nutrient arteries in relation to growing long
bones, i. e., nutrient arteries are directed toward the elbow and from
the knee, and the epiphysis, towrard which the artery is directed, unites
first. The fibula is an exception to this rule. Following this rule,
the lower epiphysis of the femur, the upper epiphysis of tibia, the lower
epiphysis of the radius and ulna, and the upper epiphysis of the hum-
erus, are the last to unite in their respective bones, and therefore must
be carefully guarded.

7. Unless a bowing deformity in the leg or forearm tends to manifest
itself rapidly, and to cause great loss of function or threaten skin necro-
sis, the correction of the deformity by the use of splints should extend
over a period of at least one year.

8. If both clinical and roentgen-ray examination during the course
of the year show that the bone is arrested in growth, a resection of the
shaft of the companion bone, remote from the epiphysis is performed

282 LEE: SURGERY OF THE EXTREMITIES

to equalize the length. The resected ends are held in apposition by
kangaroo tendon.

9. If the child is young and many years, or inches, of growth are to
be expected, the corresponding epiphysis of the accompanying bone
may be excised in order to stop its overgrowth, provided a period of
two or three years has elapsed, and it can be positively established that
the epiphysis of the damaged bone has ceased all growth. After such
treatment each bone grows at an equal rate from the remaining
epiphysis and there is no possibility of a subsequent bowing deformity
developing. Of course, a deformity in length will occur.

Chronic Bone Abscess. Brickner1 has previously called attention to
the fact that chronic abscesses of the medulla of long bones are often
sterile, and that such abscesses can be promptly cured by simply evacu-
ating them through a small opening in the bone. The recognition of
such abscesses by roentgen ray is very uncertain. In his first report
he said that they could not be so recognized, but in the last report he
qualified this statement, and claims that when the abscess is surrounded
by sclerosed bone the light area of the pus, sometimes by contrast, can
be distinguished from the denser shadow of the bony wall.

The reviewer can personally testify to this uncertainty, and has found
it to be the exception for the roentgenologist to diagnose these lesions
preoperatively.

Brickner, after exposing the overlying cortex and by opening and
retracting the periosteum, enters the abscess cavity with a j-inch drill.
With the escape of the pus, the drill is removed and nothing else is
introduced into the bone; neither probe, curette or gauze packing.
The culture is then made from the pus to determine what, if any,
living organisms it contains. A smear is also stained and examined at
once and, if many bacteria are found, the cavity should be enlarged and
prepared for chemical sterilization. If but few or no organisms are
found, a small drain of folded rubber dam is laid in the soft parts down
to, but not into, the opening in the bone, and the remaining portion
of the wound in the soft tissue closed by sutures. The purpose of the
drain is to provide for any further escape of pus from the bone, and to
act as a safety valve in case of possible suppuration in the bone cavity
or soft parts caused by dormant organisms awakened to activity. This
drain is removed and not replaced within three or four days, when the
discharge should have practically ceased ; the small opening in the soft
parts is then allowed to close by granulation. The whole process,
Brickner claims, is over in ten days, which is in marked contrast to the
prolonged disability which results from wide-open osteotomy and heal-
ing by granulation.

Osteomyelitis of the Pelvic Bones. Geist2 reports 6 cases of pyogenic
staphylococcus infection of the pelvic bones. He refers to a compila-
tion of Bergman of 35 cases in the literature. We reviewed, in 1921,
Pfeiffer's report of a series of osteomyelitis at the University of Penn-
sylvania Hospital in which there were 2. In a group of 60 cases at the

1 Surgery, Gynecology and Obstetrics, July, 1922, No. 1, 35, 84.

2 Journal of the American Medical Association, 1921, 77, 1933.

SYPHILITIC BACKACHE 283

Pennsylvania Hospital during the past three years there have been 3
eases of pyogenic osteomyelitis of the pelvic bones, 2 of the body of

the ilium and 1 of the ramus of the pubis. The treatment in no way
differs from that of pyogenic osteomyelitis in any other hone, namely,
the earliest possible opening and draining of the medullary cavity to
relieve tension. Geist says that in each one of his eases the roentgen-
ray findings were positive and of great diagnostic aid. From our per-
sonal experience, and from the general attitude in surgical literature
at the present time, this means that these operations were at a late
stage of the disease, and when the process had advanced to the stage of
necrosis. The time of election for operative treatment of osteomyelitis
is weeks before necrosis is demonstrable with the roentgen ray. In one
of our cases the diagnosis was confusing because the symptoms were
all intra-abdominal during the first week and the nausea and vomiting,
intestinal distention and diffuse, exquisite, generalized, abdominal
pain justified the provisional diagnosis of peritonitis. Subsequently,
we found that the infection was on the pelvic surface of the wing of
the left innominate bone and wras drained by trephining the bone from
an external incision.

Syphilitic Backache. Thompson1 states that syphilitic backache,
although it is a rare condition, is probably frequently overlooked.
Whitney,2 in an examination of 544 syphilitics studied at the University
of California Hospital, found 7 per centwrith involvement of the spine.
The most frequent sites apparently are the cervical and lumbar regions,
over one-half of the reported cases affecting the cervical vertebrae. It is
usually a tertiary manifestation. Pain is usually the chief symptom and
it may be sudden in onset, like an acute focal infection, or gradual,
extending over a long period of time. The pain is characteristically
greatly intensified at night. Local tenderness is usually marked, and any
attempted movements of the spine show increased rigidity and aggravate
the pain. Whitney feels that it is pathognomonic of the condition that
there is hypertonicity combined with a stiff spine. The pathology is
similar to bone syphilis elsewhere — a simple periosteitis, an osteitis or
a combination of both. Syphilis tends to new bone formation and the
consequent nodules frequently make pressure on the nerve roots.
Again, gummatous formations in the role of the bones may undergo
liquefaction necrosis. Charcot's joints may involve the spine, although
still a disputed question as to whether such joints are truly syphilitic
or parasyphilitic, a similar symptomatology occurs.

The diagnosis of syphilitic backache necessitates the careful exclu-
sion of all other factors producing backache, and the most liable to
produce confusion are osteoarthritis of the spine from focal infection,
tuberculosis, metastatic invasion of the spine from malignant tumors
and typhoid spine. Infective arthritis usually involves many vertebra?,
whereas syphilitic spondylitis is characterized by the limited number
of vertebrae involved. Tuberculosis is perhaps the most confusing
and, in the London Foundling Hospital, 70 supposedly tuberculous

1 American Journal of the Medical Sciences, July, 1922, 164, 109.

2 Journal of the American Medical Association, 1916, 66, 627.

284

LEE: SURGERY OF THE EXTREMITIES

cases gave positive Wassermanns and were cured by antisyphilitic
treatment. The Wassermaira test, of course, is of value only when
positive.

A Case of Tabetic Charcot's Spine. Funsten1 states that Charcot's
spine is a comparatively rare condition. Charcot did not have a case
in his series. Rotter,2 in 1817, described 112 cases of Charcot's joints,
none in the spine. As late as the twentieth century it was possible
to collect only 15 cases from the literature, and only 1 of these occurred
in America. The analysis of these cases, collected first by Jean Abadie,
and summarized by Cornell,3 in 1902, gave the following statistics:

Fig. 26. — Roentgenogram, showing bony deposit. (Funsten.)

Syphilis was present in 6 cases, absent in 6, probable in 3. Sex:
11 males; 4 females. Age: 11 between fifty and sixty years; the
youngest, 35; the oldest, 66. Ataxia: In 8 cases, extreme; in 6,
moderate; in 1, slight. Other lesions occurred in 60 per cent.

Tabetic joints may occur at any stage in the development of the
disease, although they seem to be more common in the preataxic stage.

1 Journal of the American Medical Association, 1922, 78, 333.

2 Die Arthropathien bie Tabikern, Arch. f. klin. Chir., 1887, vol. 36.

3 A Case of Tabetic Vertebral Osteoarthropathy, with Radiograph, Bulletin of
the Johns Hopkins Hospital, 1920, 13, 242-243.

INFECTIOUS ARTHRITIS OF THE SPINE 285

In syringomyelia Charcot's joints develop at a late stage. It is rather
characteristic that they develop rapidly, and it is interesting to note
that in the present case the roentgenograms taken only nine months
previously revealed nothing of the present condition, unless one con-
cedes a direct progression of the osteoarthritic changes.

Existence and Treatment of So-called Epicondylitis.1 The existence of
epicondylitis in the true sense of the word is denied, as this condition
has nothing whatever to do with the epicondyle. "Idiopathic" cases
are usually the result of faulty or incomplete anamneses, and can he
traced to excessive use of the hnmero-radial joint, especially in the flexed
and supinated position of the forearm. The term "epicondylitis"
should, therefore, be deleted from surgical nomenclature.

The basis of the clinical condition is an isolated capsular injury of
the humero-radial joint. Clinically, there are two groups of cases:
(1) Most of the cases are the result and expression of a chronic habitual
occupational injury of the elbow (tennis, golf players and violinists),
with the forearm simultaneously flexed and supinated. (2) A few cases
are the direct result of a local and chronic trauma, which qualifies
itself as an isolated sprain of the humero-radial joint. The pain is
localized at the epicondyle, owing to the fact that the posterior branch
of the radial nerve runs around the radial head.

Therapeutically, the chiselling off of the epicondyle for the relief
of pain is needless and unjustified.2 Alcohol injections are also useless.
Hot air and rest— not immobilization — are the best treatment: The
joint may be used in four to five weeks, although the patient should
avoid supination and flexion, or lifting of heavy objects for sometime.

Infectious Arthritis of the Spine. Arthritis of the lumbar spine trace-
able to infections is a common cause of low back pain. The cases
described by Epstein3 were characterized mostly by their mildness, by
their ability to walk, by the involvement of the vertebra? and the peri-
vertebral tissues, by the presence of lateral deviation of the spine and
by the absence of sharp, angular kyphoses. Two of the patients have
been previously treated for sciatica by means of massage and electricity;
epidural injections have been done without success. They all com-
plained of pain in the sacroiliac region and with striking frequency
they were labelled sacroiliac slipping. The course was self-limited and
several months was the average time lost from disability.

It is intended to omit any reference to gonorrheal, syphilitic or tabetic
spines, as well as those of infancy and childhood. All Wassermann
tests were negative.

In P. W. Nathan's paper on "Polyarthritis and Spondylitis," pub-
lished in 1916, after an account of a series of experimental strepto-
coccemias in dogs, he states: "It, therefore, becomes necessary to
classify the spondylitides according to the presence or absence of neural
symptoms, the mode of progression or the involvement of the ribs and
joints of the extremities. Whether these structures are involved or not

1 J. Dubs, Deutsch. med. Wchnschr., May 19, 1921, 47, 561.

2 Tarnier: Lyon Chir., 1921, 18, 25.

3 American Journal of the Medical Sciences, August, 1922, p. 40.

286 LEE: SURGERY OF THE EXTREMITIES

is simply an accident of localization and does not depend upon peculiar-
ities or essential differences in the etiology or the pathogenesis of the
morbid process. It is, then, no longer necessary to specify by name the
type of the spondylitis (Bechterew, Strumpell, Pierre Marie, etc.);
these conditions are not essentially different; they are all simple varia-
tions in the location of some inflammatory condition which, like all
inflammatory conditions, may be acute or chronic, transient or pro-
gressive, with or without permanent damage to the tissues involved."

The region of the back between the tenth dorsal level and the tro-
chanters furnishes as much food for clinical study as the romantic area
of the right upper quadrant of the abdomen. Heavy muscles cover
the spine, rendering it difficult to palpate. These same muscles cause
profound changes in symmetry of the entire trunk when their function
is directly or indirectly impaired. The bony structures are complex
in their arrangement and in close proximity to important nerve trunks,
whose irritation in the presence of joint disease, may have far-reaching
effects. As a result of the obscurity of some of these lesions, we behold
queer diagnoses and questionable healing cults.

A definite list is due to osseous thickening and muscular spasm when
we exclude evanescent cases of lumbago. It can be directly translated
in terms of inflammatory exudates, adhesions, absorption of cartilages,
destruction of bony tissue, deposits, excrescences and ankylosis. The
process in acute severe cases is one of rapid softening of a vertebral lip,
contraction or shortening of a meniscus, soon eventuating in a rounded
lumbar kyphosis. Softening and destruction of one-half of the upper
margin of the lumbar will most readily produce lateral deviation of the
trunk. These changes may occur before they are recognizable in a
roentgen-ray plate. A kypho-scoliosis coming on in the short space of
a few weeks appears to be much more of a complicated mechanical pro-
cess. It can be explained by a massive softening, destruction involv-
ing the lateral articulating processes, followed by a partial sliding of
an entire vertebral body to one side. The usual phenomena of arthritis
ankylotica follow and the organization of ligaments results in calcified
bands of spondylitis deformans.

Ankylosis of bodies, the ideal process of resolution in inflammatory
spinal disease, is "a consummation more devoutly to be wished" than
an orthopedic operation designed to splint the spinous processes.

Treatment. The treatment of infectious arthritis of the spine is essen-
tially mechanical. A plaster jacket and rest in bed are necessary to
control symptoms during the acutely painful stage. To prevent deform-
ity in certain cases, a Bradford frame may be used. Without immob-
ilization, there is always a possibility of extension of the process. Braces
are indicated for a more or less prolonged period to control recurrences.

Isolated Disease of the Scaphoid Bone of Foot. Risser1 recalls that, in
1908, Koehler,2 of Wiesbaden, reported 3 cases of disease of the scaphoid
bone of the foot, occurring in children and limited to the scaphoid.
Since then only 11 additional cases have been reported; so we may

1 Journal of the American Medical Association, March 4, 1922, No. 9, vol. 78.

2 Miinchen. med. Wchnschr., 190S, No. 37, vol. 55.

ISOLATED DISEASE OF THE SCAPHOID BOSK OF FOOT 287

conclude that the condition is not very common. The disease is scarcely
mentioned in the text-books of surgery or pathology. The etiology is
obscure, though the clinical history, symptoms and course arc fairly

Fig. 27. — Diseased foot: Scaphoid narrowed, outline ragged, granular appearance.

(Risser.)

uniform. The roentgen ray furnishes the only positive means of
diagnosis. None of the cases reported have been fatal, and none of

Fig. 28. — Diseased foot: Recovery advanced, scaphoid regaining normal size, shape
and roentgen-ray appearance. (Kisser.)

the patients have been operated upon, so that neither bacteriologic nor
pathologic studies have been made. Hence, the roentgen ray furnishes
the nearest approach to the study of the pathology of the disease.

288 LEE: SURGERY OF THE EXTREMITIES

The roengen-ray findings are fairly constant and typical, and coincide
with the clinical course of the cases recorded.

Deforming Osteochondritis of the Upper Epiphysis of the Femur in
Children. Perthes' disease— pseudocoxalgia; osteochondritis deformans;
juvenile deforming osteochondritis of the hip; softening of the epiphyses;
Calve-Legg-Perthes disease; coxa plana— has greatly interested and
disturbed surgeons abroad and in this country during this year. No
attempt has been made to review all the literature that has appeared,
but its etiology, pathology and nomenclature are still under active
discussion.

Calot and Colleu1 explain the condition as a transient phase of con-
genital subluxation of the hip-joint. This congenital malformation of
the hip-joint is responsible likewise for certain cases of arthritis defor-
mans of the hip-joint, and certain other forms of hip-joint disease in
adolescents and adults. All these apparently widely diverse affections
are related to each other, the same as the chrysalis, the cocoon and the
butterfly.

Weil2 says it can be supposed that this deformity is caused by an
intrauterine injury due to pressure. Just as this general injury may
hinder the development of the total skeleton, a local limited pressure
may lead to local disturbances of ossification.

Liek3 calls attention to the close analogy between the Legg-Calve-
Perthes, Schlatter and Kohler affections, and the fact they affect only
boys, as a rule, during the period of active growth. The bilateral,
multiple occurrence points to a constitutional factor, and he ascribes
it to some functional derangement of the epiphysis, which, in turn,
he traces to the internal secretions. The epiphysis is not sound to
start with. When slight changes exist there are merely "growing
pains." When pronounced, there is softening of the epiphysis. Mech-
anical influences are an important factor, but the morbid changes in
the epiphysis had preceded them.

Pseudocoxalgia. Piatt4 regards it as a definite entity representing the
reaction of the metaphyseal region of the upper end of the femur to
the stimulus of an infective agent of attenuated virulence. The con-
dition is comparable with the one seen solely in adolescents, and which
represents the reaction of the hip-joint to an infective agent of a similar
type. The whole cycle of radiographic changes is peculiar to pseudo-
coxalgia alone. They precede and outlast the clinical phenomena.
The final picture is dominated by the deformation of the head of the
femur, which is enlarged and flattened. The acetabulum in its final
form can no longer contain the whole of the expanded head. Deforma-
tion of the head of the femur, with flattening and expansion, is seen
also in conditions distinct from pseudocoxalgia during childhood.
There is no evidence to show that in these conditions the typical struct-
ural osseous changes of pseudocoxalgia have preceded the stage of

1 Presse medicale, Paris, p. 35.

2 Centralbl. f. Chir., April 16, 1921, 48, 517.

:1 Arch. f. klin. Chir., March 8, 1922, No. 2, vol. 119.
4 British Journal of Surgery, January, 1922, 9, 35.

TUMORS OF THE LONG BONKS 289

flattening. At certain stages the clinical and radiographic pictures of
the two groups of affections may show considerable resemblance. This
applies particularly to cases of primary tuberculous osteomyelitis of the
femoral neck. In the conditions known as tarsal scaphoiditis (Kohler's
disease) and epiphysitis of the tibial tubercle (Osgood-Schlatter disease),
bony changes parallel to those in pseudocoxalgia are found. Conserva-
tive treatment directed toward the elimination of weight-bearing has no
proven influence on the train of morbid changes, but its application is
indicated during the stage of prominent symptoms. Operative treat-
ment directed toward the removal of the dominant lesion has no
present place in the therapeutics of this disease. The controversy
over the nomenclature and the etiology of this condition increases,
instead of diminishing, as time goes on. Calve1 says that most of the
observations published are incomplete and this probably is the cause
of the confusion.

The subject is disctissed at length by Lance and Capelle,2 Pascal
Feutelais,3 Vulliet4 and Chiasserini.5

Tumors of the Long Bones. Ashhurst,6 in a discussion before the
American College of Surgeons, said that surgeons know a great deal
about tumors in general and about sarcomata in particular, in the same
way that there existed about syphilis an immense fund of information
derived from clinical observation and study, long before the cause of
that disease was known. Note, for instance, the many advances in our
knowledge about tumors since the days of Virchow: (1) First perhaps
should be placed the doctrine of anaplasia, as deduced by Hansemann
(1897); (2) then there is the classification of tumor cells according to
their derivation from the primary embryonal layers, as totipotential,
pluripotential and unipotential, for which, according to Adami, we are
indebted to Barfurth; (3) then we have the doctrine of the equivalence
of the connective tissues, endothelium, lymphatic, mucous and fatty,
cartilage and bone marrow (Malherbe, 1904), which really is not in
opposition with the doctrine of the specificity of tumor cells as taught
by that genius of French pathologists, Bard (1899).

These, you will say, are mere theories; and it is true enough that
they are mere theories, but after all are theories of no use? What
would thinkers have done through so many years without the theory
of gravitation? And yet we are now informed that this theory is false.
But everyone must recognize, in the science of medicine as in the more
exact sciences, that it is imperative to have theories of some kind on
which to hang our ideas and by which to classify our thoughts. So it
is for these purposes that Ashhurst ventures to think that the theories
he has mentioned are still of use in surgery today.

It may be admitted that any cell in the body may give rise to a tumor.
We know that some cells frequently give rise to tumors, as epithelial

1 Journal of Orthopedic Surgery, 1921, 3, 489.

2 Jour, de Chir., 1921, 18, 471.

3 Rev. d'orthop., Paris, July, 1921, 8, 315.

4 Rev. med. de la Suisse Romande, Geneva, July, 1921, 41, 413.

5 Policlinico, Pract. Sect., Rome, October 17, 1921, 28, 1394.

6 Surgery, Gynecology and Obstetrics, March, 1922, No. 3, vol. 34.

290 LEE: SURGERY OF THE EXTREMITIES

and connective-tissue cells; we know that others very rarely, if ever,
take on a neoplastic character. But actually there is scarcely any cell
in the body from which some student does not think he has observed
a tumor developing. For instance, that one recent investigator thinks
he has discovered a tumor formed from erythrocytes (red blood cells).
Though others may not agree with his conclusions, they must admit
that in theory the thing is possible.

Now we may, with advantage, go one step further in our theori-
zing, and admit that every cell which may produce a tumor may
produce a tumor of embryonal, of intermediate, or of adult type. The
tumors of adult type, which were called by Virchow, and lately by
C. P. White, histomata, are those which resemble (resemble, but do
not actually reproduce) the normal tissues; those in which no formed
tissues develop are named cytomata, and in them the cells remain of
embryonal type forever, and these tumors are malignant. But, in
accordance with the dictum, Natvra non facit saltvs, there must also
be recognized tumors which are neither histomata nor yet cytomata,
which are neither benign nor yet malignant, but intermediate in type.
And these are the tumors which are the bane of the surgeon, for the
pathologist merely replies, "I don't know," to all queries as to the
prognosis as deduced from histologic study. Thus, it is easy to recog-
nize the fibroma as a tumor of adult type derived from fibroblasts, and
a spindle-cell sarcoma as a tumor in which the fibroblasts remain of
embryonal type forever; but when some of the sections show fibrous
tissue forming and others show cells of sarcomatous nature, it is
impossible to say that the tumor is either strictly benign or decidedly
malignant.

In the realm of bone tumors, particularly, are growths to be found
about which no consensus of opinion exists among pathologists; and we
have heard much about the malignancy of true osteogenic sarcoma and
the benignancy, relative or absolute, of the giant-cell sarcoma, better
called the myeloplaxoma of Eugene Nelaton (1860), or the myeloma of
Malherbe (1904).

Now in regard to the term osteogenic sarcoma, this may be said:
Osteogenic means bone-forming; and if a sarcoma in bone forms bone,
the more bone it forms the more benign must the tumor be, because,
according to the theory of anaplasia, the fibroblastic cells are develop-
ing to their adult type, and are forming a tissue. Either, therefore,
the theory of anaplasia is wrong, or the term osteogenic is poorly chosen
to describe a very malignant form of tumor. The most malignant
form of tumor in bone should be one in which the embryonal type of
bone cell was best preserved. Such tumors have for generations been
called round-cell sarcomata; though some modern pathologists exclude
all "small round-cell sarcomata" as being really of lymphatic and not
of osseous origin, and consider all "large round-cell sarcomata" really
to be composed of fibroblastic cells very immature in type.

But it need not suprise us to learn that many a tumor might grow
in bone and yet have no pathogenetic relation to the bone proper.
For there are all the marrow cells in bone, none of which has any neces-

TUMORS OF THE LOS (I BONES 291

sary relation to osseous tissue, and yet these cells do, according to some
authorities, act as the focus of tumor Formation. Tn sonic of the lower
forms of life the marrow is not found within the hones (indeed these
particular forms of life do not have any hones); hut it is arranged as
it were in glands which discharge their products into the blood stream,
much as in the human body the secretions of the lymph glands are so
discharged.

Now, the question of most interest to us is whether any of the
forms of sarcoma of bone, as we understand that term, arc tumors
which arise from marrow cells (and these after all are connective-
tissue cells), or whether we must confine the term sarcoma to
tumors which are developed from osteoblasts and the derivatives of
these latter. Is there not something lucid and simple in the theory
of Malherbe about these sarcomatous tumors? Namely, that since
the original indifferent connective-tissue cells may, in the course of
their development, form either bone or marrow, or for the matter of
that cartilage, lymphatic, endothelial or fatty tissues, so the adult
type of tumor may conform to the type of any of these tissues,
according to the manner in which the cell develops. Thus, he recog-
nized the giant-cell sarcoma, which he named myeloma, as the adult
(benign) tumor of bone marrow; and the embryonal (malignant)
tumor of bone marrow, and named it myelosarcoma. Certainly we
occasionally see also tumors of intermediate type in bone marrow
which are neither certainly benign nor absolutely malignant. And
though the adult types of fibroma, lymphoma and endothelioma are
rare or unknown in bone, yet chondroma and osteoma (at least in the
form of exostoses) are frequent; and we may with propriety name
tumors of the intermediate type fibrosarcoma, chondrosarcoma or osteo-
sarcoma, implying that some at least of the tumor cells develop suffi-
ciently to give a tissue characteristic to the growth; while the purely
sarcomatous tumors we may, perhaps, still be allowed to name accord-
ingly to the predominant type of cell— round-cell sarcoma or spindle-
cell sarcoma.

But these question of pathogenesis must, for the present, be left
unsettled, until continued pathologic research sheds more light on the
subject.

In regard to the question of conservative treatment of bone sarcoma,
Ashhurst wrote nearly ten years ago: "The usual advice is to do
amputation as early as possible, the limb being removed at the nearest
joint above the disease. But to one who considers the ultimate
results, it is questionable whether anything is gained by this but
relief of pain. Internal metastases must often be present when the
patient first comes to the surgeon, since they appear with such uni-
formity, even after removal of the limb; and local recurrence is so apt
to follow excisions or amputation in continuity, that there is no class
of cases so disheartening." These statements apply to undoubted
sarcomata of bone. But even in what appear to be highly malignant
forms of growth, he now believes it proper to incise the tumor and secure
some tissue for microscopic study: If the diagnosis of great malignancy

292 LEE: SURGERY OF THE EXTREMITIES

is justified the exploration will do no harm; if it proves wrong, a life as
well as a limb may be saved by proper treatment.

For the benign myeloma, he is firmly convinced that amputation
is rarely justifiable. Evacuation of the tumor and complete removal
of its contents, with crushing in of its walls if the tumor is small, or
transplantation of bone if the tumor is large or if a pathologic fracture
demands fixation, seems to him the method of choice. He is opposed
to leaving to themselves, unexplored, what are thought to be benign
tumors, because recovery will seldom take place without the aid of
evacuation by the surgeon and if the tumor is of the intermediate type,
prompt operation may prevent it from becoming malignant; and many
of these benign tumors, especially in adults, have an undoubted tendency
to undergo malignant change.

In tumors of the intermediate type he believes that a conservative
operation (evacuation) should be first adopted; local radical excision is
indicated for recurrences, or even amputation in cases where truly
radical excision would leave a useless limb or endanger the life of the
patient.

He is sure it is proper to employ Coley's mixed toxins in all forms of
bone sarcoma. His own results speak for themselves; my own experi-
ence, though comparatively very limited, has taught me that their use
may not only prevent, but actually cure, recurrences of tumors belong-
ing to the intermediate type. As to radium, it appears to me that its
true value has not yet been determined.

As regards the question of pathologic fractures, he does not regard it
as of great importance. He has seen pathologic fracture in highly
malignant sarcoma, and as the first sign of disease in osteomyelitis
and in metastatic carcinoma, as well as in the benign bone cyst and in
myeloma. It is a complication of the underlying disease, but does not
alter the prognosis nor the indications for treatment.

There are so many questions still to be answered in connection with
sarcoma of the long bones that it is well for us to acknowledge our
ignorance and to plan means of increasing our knowledge. For is not
life short while the Art is long? Is not the occasion fleeting, experience
fallacious and judgment difficult?

Hemorrhagic Osteomyelitis. Barrie1 publishes the same article which
was reviewed in Annals of Surgery last year, to the effect that the
picture presented in the primary phase of hemorrhagic osteomyelitis
exhibits all the factors covering our conceptions of granulated tissue.
Early efforts at repair in any non-suppurative area of osteolysis, exhibits
a picture similar to the process termed hemorrhagic osteomyelitis, giant-
cell sarcoma, giant-cell tumor. The same picture is noted in early efforts
at bone repair after fracture. The solitary lesion has been seen and
studied by him in all bones except the skull, clavicle, scapula and
manubrium, and thus far only 1 case with multiple lesions in several
bones has been observed.

Myerding2 describes under the name of hemorrhagic cysts, very much

1 American Journal of Surgery, September, 1921, 35, 253.
- Surgical Clinics of North America, 1921, 1, I 193.

SARCOMA OF THE LONG BONES 293

the same condition as Barrie describes ;i> hemorrhagic osteomyelitis.
The cases which he describes occurred in the femur and are quite

similar to one that has been under our observation tor three years. It
was a multilocular hemorrhagic cyst, involving the entire length of the
medullary cavity of the femur. Although it had recurred after a

previous operation one year before, no signs of recurrence have followed
conservative operation of curettage.

Multiple Myeloma. Sverre Oftedal1 states that multiple myeloma
must still be classed among- the rare diseases. According to Wallgren2
there were, up to 1920, only 1 IS eases on record in which the diagnosis
had been confirmed at necropsy. While the etiology is, to a great
extent, obscure, some interesting evidences have been brought to light
by observations on the reported cases. Harbitz,3 with the possibility
in mind of its being a systemic disease of infectious origin, injected a
series of animals with tumor substance, with negative results in all
cases. Bradshaw1 reports a case in which the Bence-Jones protein was
discovered in the urine more than a year before the appearance of any
tumors. Based on this finding, he made a correct diagnosis of myeloma
with its inevitable prognosis. This would seem to suggest an etiologic
significance to the practically constant presence of the Bence-Jones
protein in myeloma. Trauma has had an important role in the history
of the reported cases. Sometimes, indeed, being of such a trivial nature
as scarcely to be noticed by the patient at the time of its occurrence;
the site of such trauma, however, in many cases having been the start-
ing-point of a late tumor. The case here reported seems to be of interest
not only from the standpoint of its rarity, but also because of the definite
history of trauma, and a period of more than one year during which
there was constant irritation of the rib surfaces by a hard rubber drainage
tube.

Sarcoma of Long Bones. Meyerding5 reports that, in the Mayo
Clinic from September, 1907, to September, 1921, 470 cases were diag-
nosed sarcoma of the extremities; 1(58 (35.7 per cent) of these were
sarcoma of the long bones. One hundred and nine of the patients were
operated on, and a microscopic diagnosis was made of sarcoma of the
femur, tibia, fibula, humerus, radius and ulna. Besides the 470 cases,
there were 18 in which a diagnosis of giant-cell tumor of the long bones
was made at operation and from microscopic examination. Fifty-nine
of the 168 patients were inoperable at the time of examination or they
refused operation. In 85 of the 109 cases the sarcoma was in the lower
extremity. It was in the femur in 49; in the tibia in 27; in the fibula in
9; in the humerus in 18; in the radius in 3; and in the ulna in 3. The
left lower femur was involved in 27; the right in 22; the upper end of

1 Journal of the American Medical Association, November 12, 1921.

2 Untersuchungen fiber die Myelomkrankheit, Upsala Lakaref Forh, September,
1920, 25, 113.

3 Multiple Primare Svulster i Bensystemet (Myelosarkomer), Norsk. Mag. f.
Laegevidensk, May, 1903, 64, 1.

4 On the Evolution of Myelopathic Albumosuria, British Medical Journal, July
13, 1901, 2, 75.

5 Surgery, Gynecology and Obstetrics, March, 1922, No. 2, vol. 13.

294 LEE: SURGERY OF THE EXTREMITIES

the left tibia in 17, and the right in 10. As to trauma causing bone
tumor, Meyerding's experience leads him to believe that the single,
hard, local injury is the type most often followed by sarcoma. Constant
irritation causes traumatic periostitis, a more severe injury often
causes a subperiosteal hematoma, which may undergo ossification rather
than absorption. The principal points to be decided before operating
are malignancy, metastasis and the extent of the bone involved. With
early diagnosis, eradication of the tumor, care to exclude patients with
metastasis, and the use of radium, roentgen ray and Coley's toxin, pro-
longation often may be looked for following operation.

Osteitis Fibrosis Cystica. A case of generalized cystic fibrous osteitis
(von Recklinghausen) is reported by Floercken.1 These characteristic
lesions involve the right tibia, the trochanter of the right femur, the
right radius and right ulna. The cyst in the tibia was removed and
the wound healed. A year later there was a spontaneous fracture
through the trochanter of the right femur. After another year there
was pathologic fracture of the surgical neck of the left humerus. This
cyst was drained, the cavity curetted and an osteoplastic strip from
the tibia grafted into the fractured ends. A pathologic fracture occurred
through a cyst in the left femur six months later. The question raised
by Floercken is whether surgical treatment is ever justified in this
hopeless condition, and after his experience he was inclined to the
opinion that unbearable pain is the only indication for the opening
of the cyst.

Bilateral Congenital Backward Dislocation of the Lower End of the Ulna.
Holzberg2 has reviewed the literature on this subject. According to
Fosdick Jones,3 there were only 2 authentic cases on record up to the
time of his writing (1911). However, there have been a number of
cases of habitual dislocation of the ulna reported. We have had 1
case of bilateral dislocation this year, congenital in type. This condi-
tion was first recognized by Dessault in 1771.

The great majority of these cases were studied before there were any
roentgen-ray opportunities. Most of these cases come to medical
attention through a traumatic incidence. This occurred in the case
herewith reported and served to call attention to the congenital
condition.

None of the cases reported up to date lay stress on the importance
of an enlarged styloid process, from an etiologic point of view. How-
ever, there were no roentgenograms reproduced with any of the reports
which would bring out this point. Holzberg reports his case with
illustrations, showing the congenitally enlarged styloid process to be
responsible for the backward dislocation. This patient came to him
with a history of trauma, and the true condition was not recognized
at first.

Manipulations of Stiff Joints. We have learned to read carefully and
take heed of advice offered by Jones,4 and his article on the manipulation

1 Med. I<Qin, 1921, 17, 1171; Surgery, Gynecology and Obstetrics, 1922, 34, 213.

2 Journal of the American Medical Association, December 24, 1921, No. 26, vol. 77.

3 American Journal of Orthopedic Surgery, 1911, 9, 199.

4 Journal of Orthopedic Surgery, 1921, 3, 385.

DEFECTS OF THE PATELLAR BORDER 295

of stiff joints is filled with those practical suggestions he is so well
qualified to give.

W hen a painful joint is rigid in all directions, arthritis is present, but
if it is rigid in certain directions only, and its movements in the other
directions are normal, it is free from arthritis.

Intra-articular adhesions may be due to rupture of the joint capsule,
hemorrhage or adhesive plications of the synovial membrane.

The Prevention of Adhesions. Following direct injury to a joint which
does not cause fracture, movement should be begun immediately after
the cessation of the acute symptoms, i. c, when the swelling and tension
pain disappeared. In children passive movements may be begun before
active movements.

Breaking of Adhesions. Light adhesions may be broken under gas
or gas and oxygen anesthesia. Complete anesthesia to obtain complete
relaxation of the muscles is necessary if the adhesions are strong and
resistant. The joint should be moved through the full anatomical range.
The corresponding limb serves as a guide to determine the range of
motion. If the adhesions are firm and resisting, the movements should
be less complete, and full mobility should be secured by stages. After
obtaining full motion, the limb should then be held in the position of
full correction until the patient is able to make a voluntary effort.
Voluntary movements should be begun as soon after the manipulation
as possible, depending upon the severity of treatment and the reaction.
If the range of motion is diminished after manipulation, the after-treat-
ment has been defective or the manipulation ill-advised.

A fracture present near a joint should be protected by means of closely
applied splints before manipulation is begun. Effusion in a joint after
manipulation is strongly suggestive of the rupture of intra-articular
adhesions, but this has no ill effects unless the effusion is accompanied
or followed by a decrease in the range of movement. In such case the
joint requires rest. The rupture of typical adhesions is audible and
may be felt under the hand, but if the resistance is overcome by gradual
stretching the prognosis is not so favorable. The joint should be kept
in its new and corrected position at rest for a few days, and gentle
passive movements then begun. Pain, which is sharp and of short
duration, is negligible, but if it continues, increased stiffness is apt to
follow, and rest is necessary.

Defects of the Patellar Border. Todd-McCally,1 becoming interested
in the large number of undiagnosed disabilities of the knee joint during
their army experience began a study, on their return to civil life of
the vast amount of material in the Hamman Museum with the especial
purpose of discovering, if possible, some adequate cause of the disability.
Since the history of the cases failed to give indubitable evidence of
trauma and the condition did not, as a rule, result from ordinary activities
in a young man's life, it seemed necessary to look for some slight lesion
or some anomaly, as the result of the presence of which, repeated slight
trauma regularly applied, such as that due to the continuous and some-

1 Surgery, Gynecology and Obstetrics, July, 1922.

296 LEE: SURGERY OF THE EXTREMITIES

what monotonous action of the knee in a route march, might light up the
condition.

There is a condition of the patella occurring in about 3 per cent of
human beings characterized by more or less marked defect of the upper
and outer part of the bone.

( 'ertain minor defects which are ill-marked and show up best when
lipping of the patella becomes a prominent feature are not included in
the estimate of 3 per cent. These occur much more frequently.

The area in which patellar defect occurs presents certain differences
from the remainder of the bone even in the cartilaginous condition. In
the adult, lipping is exceedingly slowr to make its appearance in this
area. Pathologic conditions of the articular surface are prone to
present themselves in this area.

The area to which reference has just been made is known as the area
of emargination. It is associated with the attachment of the vastus
lateralis tendon.

Patellar emargination may occur as a very slight defect. There
may be a much larger defect in the bone, which may, or may not, be
occupied by a separate ossification. Again, there may be incomplete
separation of the patellar portions.

Associating with, or occurring in place of, patellar defect, there may be
a condition of deep pitting of the articular surface.

No indication of recent or old callus formation is present on any of
our specimens, whether of complete or incomplete separation of the
patellar portions.

No indications of inflammatory processes occur in relation to either
patellar defect or excavation.

Lipping of the margins of the emarginate area occurs with age; this
must not be mistaken for callus formation.

A history of trauma is not given by the cases in which patellar defect
is found.

The condition occurs on both sides twice as frequently as upon one
side.

There is no convincing evidence that the condition occurs more
frequently with increasing age.

They have been able to present all phases of the development of
the condition, although the results of their investigations upon children
are unsatisfactory.

There is no doubt that the patella sometimes ossifies from separate
centers in the vertical axis. They have presented specimens showing
the probability of other centers of ossification in individual instances.

As the result of the findings just summarized, they believe that the
condition is an anomaly and not a fracture.

Chronic Infectious Arthritis. Billings, Coleman and Hibbs1 state that
the management and treatment of this group of patients was based on
the principles that relate to the cause, mode of infection, and the
character, of the morbid anatomic changes. Primarily, this involved

1 Journal of the American Medical Association, April 15, 1922, No. 15, vol. 78.

DELTOID PARALYSIS AND ARTHRODESIS OF SHOULDER JOIST 297

the location and eradication of the apparent etiologic focus of infection.
The location of the real focus of infection was difficult occasionally, and
at times impossible. The diagnosis and location of the primary focus
sometimes required the highest clinical skill and the cooperation of
qualified specialists, laboratory investigation and the use of diagnostic
instruments of precision, including the roentgen ray. In some patients
the failure to eradicate completely the etiologic focus by surgical meas-
ures defeated the subsequent management and treatment.

The clinical investigation confirms and substantiates the present
point of view of a majority of clinicians who have had the opportunity
to make a careful investigation of chronic deforming arthritis, that it is
primarily an infectious disease, and that the infectious microorganisms
which are the cause are usually strains of non-hemolytic streptococci of
relatively low virulence, or occasionally strains of non-pyogenic gono-
cocci or even of other bacteria of mild pathogenicity.

The cause of the remarkable transformation of the fibrous tissues
which enter into the joint structure and also of the muscle tendons, into
bone, is an interesting subject for future investigation. If the remark-
able results of the animal experiments reported by Oxhausen1 can be
substantiated, it may be possible to apply preventive measures which
will obviate these disabling irremediable secondary morbid changes.

Synovial Cysts and Tuberculosis. Polycystic Tuberculous Disease of
the Wrist. Positive Inoculations of Guinea-pigs with Cyst Fluid. Various
theories have been held concerning the pathogenesis and etiology of
cysts about the wrist joint. Several authors have shown the importance
of tuberculosis in this connection, this disease existing under some form
in the patients themselves or their immediate family, in several cases
reported. Gougerot's2 case is the first where inoculation of a guinea-pig
with the cyst fluid gave positive results.

These synovial cysts belong, therefore, to a general category of serous
membranes which become tubercular. That all cysts of the wrist are
tuberculous is not true. Except in the case of very small cysts, excision
is usually necessary, followed by immobilization of the wrist in a small
plaster for about fifteen days. After this a leather supporting bandage
is advisable.

Deltoid Paralysis and Arthrodesis of the Shoulder-joint. Straub3 states
that the picture of this lesion, which is a rather rare object for treatment
by the surgeon, is a lamentable one: The changed contour of the
shoulder, undue prominence of the acromion, coracoid and head of
humerus, the subluxation of the joint, inward rotation of the arm, the
flail shoulder, with the limb practically a useless appendage of the body.
Though the function of the forearm and hand may be entirely preserved,
they are rendered useless in this condition through the inability of the
patient to move them to the desired place of action.

While medical and mechanical treatment may be indicated in recent
or partial deltoid paralysis, it is the inveterate case wThich usually

1 Verhandl. deutsch. Gesellsch. f. Chir., 1912, 62, 40.

2 Paris medicale, October 29, 1921, 11, 333.

3 Surgery, Gynecology and Obstetrics, April, 1922, No. 4, 34, 476.

298

LEE: SURGERY OF THE EXTREMITIES

applies to the surgeon and it is a new method suggested by Straub that
we wish to present at this time. His object is to obtain a bony fusion
of the joint. After exposing the joint by a four-inch incision carried
from a point half an inch internal to the acromial clavicular joint down-
ward to the outer side of the pectoro-deltoid groove, the joint is opened
alongside of, and internal to, the biceps tendon. The tendon is then
lifted out of the sulcus between the tubercle and is placed laterally.
The capsule is then dissected off the anatomical neck and the head of the
humerus can be conveniently dislocated, when the synovial membrane
is excised as thoroughly as possible. The cartilage of the dislocated
head of the humerus is then excised down to the cancellous tissue and

Fig. 29 Fig. 30

Fig. 29.— Ante-operative roentgenogram, showing subluxation of shoulder joint.
(Straub.)

Fig. 30. — Postoperative (twelve weeks) roentgenogram of shoulder joint, the
humerus is firmly united to the scapula, the bony fusion in the glenoid fossa is shown,
the osteogenetic process is creeping up along the bone peg. The angle made by the
outer edge of the scapula and the humerus is slightly more than 90 degrees. (Straub.)

in a like manner the cartilage is removed from the glenoid cavity, care
being taken to preserve the insertion of the biceps tendon. With the
scapula fixed in its normal position, the head of the humerus is returned
into the capsule and closely approximated to the glenoid cavity and the
acromion. In order to insure for the patient the most use of his hand,
the humerus should be ankylosed at about a right angle abduction to
the body (the external border of the scapula forming an angle of 80 to
110 degrees with the axis of the humerus) . This is the position by which
the hand can reach the mouth, head and neck and also the upper arm
will comfortably touch the lateral chest wall in the position of rest.
With the arm in this position, a hole is drilled through the acromion into

INTRINSIC DERANGEMENT OF THE KNEE JOINT 299

the center of the head of the humerus, the <lrill being left in place while
«i small dowel-peg is secured from the tibia, and then the drill is removed
and driven into the hole. The smooth intertrochanteric groove for a
distance of about one inch is converted into a rough bony trough by
lifting up the periosteum and under the periosteal flap the biceps tendon
is buried and the periosteum united by kangaroo tendon sutures. The
parts an- immobilized by plaster for twelve weeks.

Intrinsic Derangement of the Knee-joint. Henderson1 justifies the
distrust of the knee as a proper field of surgery by the crippling dis-
ability of ankylosis or amputation which follows infection and the living
latent example of surgical disaster such a patient presents in contrast
to those who die from peritonitis following a clean abdominal operation.
But our war experience, and especially the mobilization treatment of
infected joints as advocated by Willems, has demonstrated that infec-
tion in surgery of the knee-joint can be controlled as elsewhere, and that
there is no more need for fear of exploring this field than the exploration
of any other closed serous cavity of the body.

The semilunar cartilages rank first as a cause of mechanical derange-
ments of the knee. The English literature contains many reports,
notably by Rutherford Morison and Sir Robert Jones, of large series of
patients operated on, but the American literature is scanty. This can
be explained, partly at least, by the fact that games, such as rugby and
soccer, are participated in by a much larger number of persons than in
America, and also by the fact that in the mines in the region of New-
castle, where the condition is very common among the miners, the
workers labor in low seams, which makes it necessary for them to squat
on their heels with knees flexed and feet everted, a most favorable posi-
tion for damage to the menisci. The fact that the internal cartilage is
more often damaged than the external can be explained by anatomic
facts. The internal cartilage is so firmly attached to the internal
capsule that when caught between the bones, if the force continues, the
cartilage will tear or fracture before it is torn from its moorings.

Rutherford Morison has described in detail many types of fractures,
but the so-called " bucket-handle" is probably the most common. This
specific tear is a longitudinal rip in the middle portion of the internal
cartilage, leaving the torn area attached at the anterior and posterior
ends, the loop thus formed slipping into the intercondylar notch. Full
extension is thereby prevented and the joint locked in slight flexion. A
definite pathological condition, as evidenced by a tear or fracture, is
almost invariably present when the derangement is due to the internal
cartilage.

The external semilunar cartilage at its periphery is loosely attached
to the capsule and this fact permits the meniscus a certain mobility and
allows it to glide out of harm's way. If it is the cause of the derange-
ment, it usually is found crumpled up rather than torn, and is more apt
to prevent flexion than to limit extension. The condition is usually a
loose, rather than a torn, cartilage.

1 Surgery, Gynecology and Obstetrics, May, 1922, No. 5, 34, 681.

-300 LEE: SURGERY OF THE EXTREMITIES

The primary derangement should be treated conservatively but
repeated lockings, with periods of disability, make it necessary to resort
to surgery. The roentgen ray is of no value, as these fibrocartilaginous
menisci cast no shadows. The procedure of injecting the joint with
oxygen, thus throwing the fibrocartilages in relief, is too dangerous a
procedure to warrant its use.

Loose osteocartilaginous bodies are also a cause of mechanical derange-
ment of the knee, but the symptoms are more transient and the disability
less than when the menisci are at fault. In numbers, they range from
one or two up into the hundreds. Usually, the patient has palpated
them and often is able to force them out where the surgeon can also feel
them. They are readily shown by the roentgen ray. Not infrequently
both joints are involved. They are of chief interest from the viewpoint of
etiology. As a primary promise, it may be accepted that trauma, direct
or indirect, is a factor, but not the sole factor in their production. They
may be grouped under three divisions. They may arise from the
internal condyle just anterior to the insertion of the posterior ligament.
A satisfactory explanation of this peculiar condition, seen only in the
knee joint, has not been advanced, but Koenig, in 1887, offered the
theory that it was due to blockage of an end-artery and called the
condition "osteochondritis dessicans." They may arise incidental to
osteoarthritis. The marginal osteophytes or ecchondroses become
chipped off and wander freely about the joint cavity and increase in
size, obtaining their nourishment from the joint fluid. Occasionally,
the synovial membrane undergoes a peculiar change, becoming thick
and pleated, forming bulbs, which become osteocartilaginous on the tips,
and, as they increase in size, drop off and migrate as free bodies. They
take nourishment from the joint fluid, further increase in size, and may
be so numerous that in palpating the knee, one is reminded of a sac of
marbles. This condition is called "osteochondromatosis," and is not
confined to the knee joint, but may be found in the elbow or shoulder
joint. It suggests in some ways a benign neoplasm. Osteocartilaginous
bodies rarely arise from the tibia or patella. Loose foreign bodies of
extrinsic origin are of very rare occurrence in civil practice.

The incisions to be used in the removal of the causes of mechanical
derangement are of importance because the joint cavity is not easily
explored. When one of the semilunar cartilages is to be removed, either
the internal, anterolateral or the external, antero-lateral are to be pre-
ferred to any other. When a thorough search of the anterior compart-
ment of the knee joint is to be made, the longitudinal split patella
incision is the incision of choice. When the bodies to be removed are
in the posterior compartment, the posterior, internal lateral or the
posterior, external lateral incisions made with the knee flexed to a right
angle afford ready access to a rather inaccessible region and even a fair
degree of opportunity for visual inspection.

Postero-lateral Incision for the Removal of Loose Bodies from the Posterior
Compartment of the Knee-joint. Henderson1 recalls that the posterior

1 Surgery, Gynecology and Obstetrics, 1922, 24, 6.

POSTERO-LA TERAL L\< 'IS/OX FOR REMOVAL OF LOOSE BODIES 301

Tendon 0/ biceps u

Fetaicc

12LL_._J

Fig. 31. — External postero-lateral incision. Insert shows loose body. (Henderson.)

■

Fern. u-C.
5eTnimeTnbcQno6u.a m. \j*EgS

J~ibia

■ S ac+ociixs "HI.

. GcaciUs m.

^HHBkfj

Fig. 32.— Internal postero-lateral incision. Insert shows knee flexed to the right
angle, and the position of the leg on the operating table. (Henderson.)

302 LEE: SURGERY OF THE EXTREMITIES

compartment of the knee-joint is practically divided by a mesial septum
into internal posterior and external posterior compartments. A
postero-lateral incision is therefore often necessary on both sides, in order
that the exploration for the bodies may be completed, but both incisions
are small and practically no dissection is needed.

The knee is flexed to a right angle, thus relaxing its posterior capsule.
If the loose bodies are all in the outer division of the posterior compart-
ment, the incision should be made posteriorly, well on the outer side but
in front of the fibula (Fig. 31) . A semilunar incision, with the convexity
anteriorly or posteriorly, may be made in the skin, and a straight incision
parallel with the longitudinal axis of the leg made in the capsule. This
may be enlarged, and retractors placed to give an excellent view of the
posterior cavity of the joint. A large curette or gall-stone scoop may be
used to explore and remove the loose bodies. The mesial septum
prevents ready access to the inner compartment, and, if exploration on
that side is necessary, rather than to cause trauma to the interior of the
joint by forcing an instrument through it, an incision similar to the one
just described should be made on the inner side. This is anterior to the
relaxed tendons of the semitendinosus, semimembranosus, sartorius, and
gracilis muscles.

Fig. 33.— Jones' knee brace with pad attached. (MacAusland and Sargeant.)

Recurrent Dislocation of the Patella. MacAusland and Sargeant1
state that this condition is a lesion peculiar to young girls during their
period of growth and apparently tends to persist into adult life. The
first displacement usually occurs between the twelfth and the eighteenth
year and is, as would be expected, more painful than subsequent ones.
Knock-knees are probably the chief predisposing factor, while injury is
the direct cause. Anatomically, the most frequent lesions which
contribute to the condition are the lateral attachment of the tendon and
faulty development of the external condyle of the femur. The trauma
which usually produces it consists in an inward twisting at the knee
combined with a blow or pressure on the outer side of the leg, and
associated with these factors is always a sudden strong contraction of the

1 Surgery, Gynecology and Obstetrics, July, 1922, No. 1, 35, 35.

RECURRENT DISLOCATION OF THE PATELLA

303

quadriceps muscle. The diagnosis, of course, is made by the flexion of

the knee and the displacement of the patella to the outer side of the
condyle, and the exact position of the patella is determined by the
roentgen-ray. MaeAusland and Sargent outline the treatment for the
acute and chronic luxations.

(a) Acute Dislocation. The bone can be easily reduced by sudden
extension of the leg with pressure of one hand against the outer condyle
of the femur and then pushing the patella toward the medium line.
The joints should then be immobilized with plaster for at least three
weeks and they think that if this was done more frequently after the
original injury there would not be so many recurrences.

Fig. 34. — Showing method of transplanting bony insertion of patella tendon.
(MaeAusland and Sargeant.)

(b) Recurrent Dislocations. They describe four lines of treatment
which may be grouped into (1) supportive; (2) stimulative; (3) correction
of static errors; (4) operative.

1. The supportive treatment in the earlier attacks gives the patient
confidence. A split knee-cap with a crescentic pressure pad to aid in
holding the patella in place, or a Jones knee brace, are indicated.

2. The stimulative treatment consists in baking and massage and
appropriate exercises to strengthen the muscles and ligaments and
develop postural strength.

3. The correction of static errors is most important. In many of
these cases there is marked abduction of the feet and the correction of
this deformity counteracts in a mild degree a moderate knock-knee.

4. Of the operative methods, capsulorrhaphy alone has been a distinct

304

LEE: SURGERY OF THE EXTREMITIES

failure and in the 16 eases they have operated upon they have found that
a transplantation of a part of the patella tendon has been, in all cases,
followed by good results. The technie which they advise is essentially
a transplantation of one-half of the patella tendon with its bony insertion.

Through a curved incision made over the inner side of the patella,
the tendon is exposed. An incision through the center of the patella
tendon from the lower edge of the patella to the tubercle is then made.
A wedge of bone about 1 cm. square is then removed from the tibia,
which includes the attachment of the inner half of this divided patella

RESULTS OF EX TENSIVE KNEE RESECTIONS TN WAR SURGERY 305

tendon. A similar symmetrical bony wedge is removed from the inner
surface of the tibia to the inner side of the first wedge and at a point
where the transposed end of the split patella is to be reinserted. The
bony transplant with the attached patella tendon is forcibly wedged
into its new bed and the button of bone then placed in the hole remaining
after the removal of the bony insertion of the tendon.

Mouchet and Dnrand1 report a bilateral dislocation, and describe an
operation differing slightly from that of MacAusland's.

Fig. 39.— Interrupted sutures fixing the patellar structures in their new position.

Treatment of Septic Knee-joints. During the last year the literature
has contained more and more favorable references of the Willems treat-
ment of infected knee-joints. Weatherbe2 reports his experience and
believes with so many others that this method of treatment apparently
gives the best prognosis as regards both life and function. There are,
however, a few men who still are unconvinced. Ober3 reports an
experience based upon 100 war cases in which he tried to point out the
limitations of the treatment by mobilization. The limitations seem to
us to be more like excuses, and to say that a contraindication is that
it must be entrusted only to well trained nurses and orderlies, is rather
an indication that the surgeon should provide adequate care for such
a serious condition.

Results of Extensive Knee Resections in War Surgery. Before the war
it was generally believed that amputation was preferable to a resection
of the knee which shortened the limb more than 10 cm. During the
war, however, resections of this kind were common, and the final results
in many cases of extensive knee resection were studied by Patel.4

He traced 19 patients on whom he performed resections of the knee for
war wounds in 1917 and 1918. In each case the resection exceeded 8 cm.
Three of these patients died later from influenza. Of the remaining 16,
3 subsequently had a secondary amputation and 13 have recovered.

1 Jour, de Chir., 1921, 18, 225.

2 Lancet, 1921, 201, 1271.

3 Journal of Orthopedic Surgery, 1921, n. s., 3, 689.

4 Bull, et mem. Soc. de Ohir. de Paris, 1921, 67, 619.

306 LEE: SURGERY OF THE EXTREMITIES

In 2 cases the shortening is 8 em.; in 1, 9.5 cm.; in 1, 11.5 cm.; in 3, 12
cm.; and in 4, 14 to 18 cm. These patients are unable to walk without
the aid of prosthetic appliances. The cases in which extensive resections
were done were principally infected articular fractures or knee resections
followed by non-union and sepsis.

Roentgen-ray examination some months after union in cases of re-
section of the knee reveals interesting anatomical changes; the tibial
end is thickened and the femur shows bone stalactites and is ensheathed
by two lateral bony projections which suggest two femoral condyles
grafted to the upper extremity of the tibia. A most remarkable bone
adaptation results which assures solidity of the new ankylosis and con-
stitutes further proof that in a young person the osseous system is
constantly changing and that when infection is arrested osteogenesis
continues.

Roentgenographs taken two years or more later show complete
fusion of the two bones, the femoro-tibial mass being thickened
throughout its entire extent. This is the end-result.

Antero-lateral Luxation of the Vertebral Column Reduced by Operation.
Constantini and Duboucher1 report a case of a man, aged forty-five years,
whose spine was injured in an automobile accident. The roentgen ray
showed the following deformities. (1) Right antero-lateral luxation of
the second dorsal vertebra on the third. (2) Overriding of the lower
articular processes of the second lumbar vertebra on the pedicle of the
third. (3) Downward displacement of the right part of the body of the
third lumbar vertebra which was more marked in its anterior portion.
(4) Fracture of the transverse processes of the second and third lumbar
vertebrae on the left side, opposite the lateral luxation of the body of
the second lumbar vertebra. After unsuccessfully attempting to reduce
the luxation by suspension and traction, they were able to replace them
by an open operation. It is this kind of problem which one cannot
help wishing to submit to the so-called osteopaths and chiropractors
who claim such miraculous ability in replacing imaginary, or at least
undemonstratable, subluxations.

Flat-foot and Rheumatism.2 Attention is again called to the careless
and not infrequent diagnosis of rheumatism for pains in various portions
of the body associated with tendons, muscles or nerve trunks. In rare
instances this may be a correct diagnosis in the sense that these pains
are due to the deposition in these portions of the body of the products
of impaired metabolic processes, and probably the term "rheumatism"
is just as accurate as would be the term " lithemia" or " gout." All too
frequently, however, the condition is not one dependent upon perverted
metabolism, but results from some fault in ligamentous or bony struc-
ture whereby stresses and strains are induced which are the real cause
of the suffering.

Sciatica is not as common a diagnosis today as it used to be, now that
pathologic conditions in the hip-joint and in the sacroiliac joint are
better recognized, and pains in the legs and feet are frequently the

1 Rev. d'orthop., 1922, 29, 27.

2 Therapeutic Gazette, December 15, 1921, No. 12, 45, 857.

FLAT-FOOT AND RHEUMATISM 307

result of flat-foot or faulty position of the ankle-joint particularly in per-
sons who, with advancing age, gain greatly in weight and whose bony
and ligamentous structures are, therefore, subjected to an amount of
strain which they escape in earlier years.

In other cases, pain does not develop, but the feet and ankles become
somewhat swollen, developing a true edema which will pit on pressure,
or a puffiness which will not pit, somewhat resembling a condition in
the horse which veterinarians call " wind-gall," which condition leads the
physician to suspect some cardiac or renal disturbance, yet a careful
examination will fail to reveal any feebleness of the heart or any abnor-
mality in the urine. Upon the patient reducing weight, or upon the use
of properly made shoes or supports for the parts which are under strain,
the puffiness to which wre have referred disappears.

It is noteworthy that in all the cases which we have described most
of the remedies employed, which are intended for a rheumatic or gouty
diathesis, utterly fail, although the salicylates may for a time seem to be
successful in that they tend to relieve pain, and this temporary success
often still further misleads the physician as to his diagnosis.

It is not to be forgotten, on the other hand, that some persons who have
flat-foot or a turned ankle suffer from no pain whatever, and again there
is a third class in wThich these weaknesses or deformities are present and
are entirely free from pain at times and then suffer from severe attacks
of it, because in these patients a combination of stress and strain with a
gouty diathesis results in the strained parts suffering from both stress
and gouty deposit. In such cases adequate support to correct the
weakness or deformity, regulation of the diet, and the employment of
the salicylates or other drugs belonging to this class, prove successful.

THE R A P E DTIC REFEREN DU M .

By II. R. M. LANDIS, M.D.

Acacia. During the war the intravenous use of acacia for trans-
fusion was advocated as a means of supplanting blood transfusion
which was not always available. It was sponsored principally by
Bayliss. At present its value is a matter of dispute. Accidents have
been reported and, in addition, there is a lack of agreement as to its
beneficial effects among surgeons who have used it. Furthermore,
there is some experimental evidence reported as to its harmful effects.
Several investigators have shown that it may do harm in several ways.
It may produce agglutination, both intravenously and outside the
body. It may cause pulmonary emboli, accompanied by symptoms
resembling those of anaphylaxis. It may, on the other hand, interfere
with the normal coagulation of the blood, and so be harmful by dis-
couraging hemostasis.

Bayliss3 has written an article in defense of the procedure. He points
out that, at the end of the war 75 liters a day were being supplied to the
British Army in France, and that just after the Armistice a conference
of consulting surgeons and others was called in order to discuss the
use of acacia solution. It was agreed that no harm was to be appre-
hended from the proper use, while stress was laid on the importance
of the purity of the acacia and the method of preparation.

Bayliss refers to an unfavorable experience which the British Army
had in Italy. A sample of the acacia used was found to leave a large,
dirty, insoluble deposit. This, when placed in solution, was found to
be quite useless when tested on cats.

An editorial criticism2 concludes that experience with the procedure
has not been sufficiently long for a thorough appraisal of its use as a
therapeutic remedy.

Henderson and Haggard3 believe that the most important factor in
a case of serious hemorrhage is the acapnia produced by a deficiency
in the number of blood corpuscles rather than the fall of blood-pressure
following a decrease in blood volume. Replacement of the blood with
gum, in their experiments, did not relieve the air hunger and its attend-
ant muscular exertion and over ventilation. Life was, therefore, only
prolonged and not preserved. In commenting on the work of Hender-
son and Haggard, Hare states that it rests with the advocates of gum
infusion to bring forward more evidence of the clinical efficiency of this
substitute for the physiologic remedy.

1 Journal of the American Medical Association, June 17, 1922.

2 Ibid.

3 Abstract, Therapeutic Gazette, July, 1922, p. 495.

310 LANDIS: THERAPEUTIC REFERENDUM

Lee1 reports 2 deaths following the intravenous injections of acacia.
He states that both patients presented symptoms which are claimed
to be indications for the use of acacia. Neither patient was moribund,
and there was no reason to believe that both patients could not have
survived the time period during which death occurred had not acacia
been injected.

The acacia was of the usual variety; the solution was freshly pre-
pared, neutralized and filtered according to the directions of Bayliss.
In Lee's opinion the main difficulty is not with the making of the
solution, but with what happens when the acacia is introduced into
the circulation. From his experience, Lee concludes that no beneficial
effects occurred. On the other hand, definite and immediate deleterious
effects were observed in 1, and death was accelerated in both patients
as a result of the acacia. He, therefore, believes that acacia is not an
absolutely harmless agent when used in shock, hemorrhage and allied
conditions.

Acetylsalicylic Acid (Aspirin). Some years ago Fetterolf called
attention to the value of powdered aspirin in the treatment of tonsillitis.
He found that, applied locally and thoroughly rubbed in, the attack
was usually aborted. Heller2 reports excellent results from this use
of the drug after tonsillectomy and in acute pharyngitis. His report is
based on nearly 1000 cases convalescent from tonsillectomy. His pro-
cedure is as follows: To patients convalescent from tonsillectomy he
administers 1 to 3 gr. of powdered aspirin on the tongue, on the evening
of the first day, or about eight to ten hours after the operation. They
are then given the same dose ten or fifteen minutes before each meal
for three or four days. Relief is almost universal. Heller stated that
in the past eighteen months he can recall but 2 patients who did not
voluntarily state that they were relieved. Most patients are able to
swallow comfortably immediately the powder has passed the oropharynx.

In patients with an idiosyncrasy to the drug, or in whom ingestion
of the drug is contraindicated, a weak solution (3 dg. to 30 cc of water)
is given as a gargle, and with practically the same effect as when the
drug is swallowed. This fact proves conclusively, he thinks, that it is
not the systemic effect that does good.

In acute pharyngitis and simple acute tonsillitis a powder of 1 to
3 gr. of the drug is prescribed every three or four hours to be taken on
the tongue without water. The results are identical with those observed
in postoperative tonsillectomies.

Leech3 has studied the change in acetylsalicylic acid in sodium citrate
solution. He states that while it has been claimed that acetylsalicylic
acid may be dispensed in a solution of sodium citrate without decompo-
sition of the acid, his studies show this to be incorrect. He found that
after four days the acetylsalicylic acid is broken down to the extent
of 50 per cent; after nine days to 75 per cent; and that in seventeen
days it is almost complete hydrolyzed.

1 Journal of the American Medical Association, August 26, 1922.

2 Therapeutic Gazette, December, 1921.

3 Journal of the American Medical Association, January 28, 1922.

ALCOHOL 311

Adrenalin. The use of adrenalin subcutaneously will cut short an
attack of asthma more rapidly than any other method, according to
Hurst.1 lie states that the most efficient dose is one much smaller
than is generally given. In many cases 1 minim of 1 to 1000 adrenalin
chloride solution is enough; more than 2 minims are rarely required.
To obtain results, however, the injection should be given at the begin-
ning of the attack, and not half an hour or an hour later when the
attack is fully developed. The relief is so immediate that Hurst
states the patient will often fall asleep within a few minutes. These
small doses give rise to no unpleasantness, such as frequently follow
the injection of larger doses, and they can be continued for long periods.

De Valle2 reports a case of polyneuritis which was cured with adrena-
lin. Daily injections of 1 mg. brought about improvement in a week
and in five more weeks the cure was practically complete.

The effect of adrenalin on the blood-pressure is wrell known. Phean
and Parkinson3 state that adrenalin also influences the heart, both
through the sympathetic and through the vagi. In reporting a case
presenting the Stokes-Adams syndrome they quote a number of observa-
tions on the effect of adrenalin on heart-block. They state that the
clinical evidence shows that it is possible for partial block to be reduced,
and for even complete heart-block to be abolished, by subcutaneous
injections of adrenalin; though often it fails to modify the conduction,
as one might expect from the nature of the pathologic lesion usually
present in such cases. An increase in ventricular rate, however, is usu-
ally obtainable despite the block. This alone, they believe, is a suffi-
cient ground for an extended trial of adrenalin in Stokes-Adams attacks,
where the immediate cause of the loss of consciousness is usually extreme
ventricular slowing and standstill.

Alcohol. The restrictions placed on the use of alcohol as a drug by
the Prohibition Law continues to be a subject of discussion. The
consensus of opinion seems to be that there is need of a distinction.
It matters little whether the physician himself be an advocate or an
opponent of the law, nearly all are agreed that they should be allowed
to employ alcohol as they would any other drug and without annoying
restrictions.

An editorial article,4 in discussing the subject, quotes a number of
physicians practising different specialties to the effect that they feel
alcohol has a distinct place and should not be restricted in its use as
a pharmacologic agent. The editorial in question closes with the
statement that "the renewed discussion of this important problem
is separated as far as possible from the use of alcohol as a beverage
and from its employment in social life. It deals solely with the ques-
tion of whether alcohol, properly used, is one of the agents which
physicians should be trained to employ skilfully in the treatment of
disease. We think the answer is emphatically in the affirmative."

1 New York Medical Journal, March 15, 1922.

2 Siglo Medico, February 4, 1922; Abstract, Journal of the American Medical

3 Lancet, May 13, 1922. 4 Therapeutic Gazette, January, 1922.

312 LANDIS: THERAPEUTIC REFERENDUM

Wallace,1 in calling attention to the restriction placed on physicians
in the prescribing of alcohol, states that there are signs at present of a
growing desire on the part of some individuals and some groups to
restrict, by legislative proceedings, the drugs a physician may prescribe
in his practice. Without entering into a discussion of the merits of
prohibition, or the necessity of medical restriction in enforcing it,
WTallace thinks that the medical profession should vigorously oppose
such restriction. A majority opinion as to the value of any particular
drug does not necessarily carry any more weight than a minority one.
A physician in charge of a case automatically assumes full responsibility
for it, and he should in no way be hampered in his management, pro-
vided he acts in good faith and to the best of his ability and judgment.
There should be laws in force which inflict a sufficient penalty on those
who, through ignorance or cupidity, fail to safeguard the welfare of
their patients. Wallace believes that the principle of restricting the
legitimate use of drugs is a bad one, that it will react badly on the
profession, and that it ought to be actively combated.

Wallace, while admitting that opinion varies as to the various con-
ditions in which alcohol is of value, is himself convinced that it is of
the greatest service in the treatment of typhoid fever and in the man-
agement of circulatory disease.

As in the case of other remedies, the exact workings of which are
unknown to us, alcohol does apparently exert a favorable influence.
As a matter of practical importance, it is not necessary to prove this
by scientific animal experiments. In the long run, clinical experience
is the best guide, and must to some degree be individual. Thus, one
man is a firm believer of a certain thing, another is skeptical. We
have just quoted an article by Wallace on the use of alcohol in the
treatment of typhoid fever— his belief being that alcohol is a food and,
in addition, stimulates the appetite. Haneborg2 has recently issued a
long report of the result of his work carried out in the Physiological
Institute of the University of Christiana. He concludes that the
belief that alcohol is a stomachic is not borne out by his investigations.

Since prohibition went into effect, the question of wood-alcohol
poisoning has become most important. It is highly desirable that
medical men should be familiar with its manifestations. And it is
even more desirable that the laity be more thoroughly apprised cf
the danger. Ziegler3 epitomizes the essential features as follows:

1. WTood alcohol is the most deadly poison used in daily commerce.

2. One teaspoonful has been known to cause blindness and 1 ounce
to cause death.

3. The port of entry may be through the mouth, nose or skin.

4. Wood alcohol should be identified by Robinson's test.

5. It is a protoplasmic poison possessing a selective affinity for the
delicate nerve tissues of the eye.

1 Medical Record, January 14, 1922.

2 Acta Medica Scandinavica, November 7, 1921.

3 Journal of the American Medical Association, October 8, 1921.

ALCOHOL 313

('». Its biochemistry is modified by oxidation, first to formaldehyde
and then to formic acid, both of which arc corrosive poisons.

7. Formic acid is the end-product excreted by the kidneys.

8. If formic acid is present in the urine it will promptly reduce
Fehling's solution, thus suggesting to the inexperienced a false diag-
nosis of diabetes.

9. Van Slyke's test will reveal acidosis in the early stages and alka-
losis later.

10. Sudden blindness, with vomiting and abdominal pain, should
always arouse suspicion of methyl-alcohol poisoning, especially if
diplopia or ptosis is associated.

1 1 . Papillitis, sector-like atrophy and sudden sclerosis of the nerve-
head are equally typical fundus lesions.

12. Symptoms of pituitary injury are most suggestive in pointing
to this as the primary and fundamental lesion.

13. Contracted fields and central or paracentral scotomas are
usually present.

14. Treatment should include early neutralization by alkalis, and
elimination by lavage, emetics, diaphoretics and rapid oxidation,
together with stimulation of the optic nerve by negative galvanism
applied directly to the eye. Thyroid extract and pituitary extract
may be indicated.

15. The manufacture and sale of wood alcohol should be prohibited
or regulated by law.

16. If sales are permitted, safeguards and warnings should be required,
and the public instructed as to the great danger to vision and life.

17. A special revenue tax with registered "poison sales" would
regulate and record its distribution and, in cases of poisoning, reveal
the source.

18. This tax should equalize the cost of denatured alcohol and
methyl alcohol and thus remove the temptation to adulteration because
of cheapness.

19. All wines, whiskies, toilet articles and "patent medicines"
imported from foreign countries should be tested for wood alcohol
before passing through the customs inspection.

20. The name "methanol" specifically designates this product and
yet avoids the tempting suggestiveness of the word "alcohol."

Rostedt1 states that since the complete prohibition of alcohol in
Finland serious eye conditions have totaled 60. In 50 per cent of the
60 cases blindness followed, while amblyopia was pronounced in all.
The usual disturbances developed about the third day in the majority,
and then continued a progressive course for from two to four weeks,
after which there was usually slight improvement, but it was only
transient as a rule.

An unusual complication following wood alcohol poisoning is reported
by Barbash.2 In this case occlusion of the brachial artery was noted

1 Finska Lakaresallskapets Handkngar, March-April, 1921; Abstract, Journal
of the American Medical Association.

2 Journal of the American Medical Association, February 11, 1922.

314 LA NDIS : T II ERA PE U TIC RE FE REND UM

on the ninth day after the poisoning, and six days later an attempt was
made to remove the thrombus. It was found that the entire arterial
tree of the forearm and hand was filled with clot. The hand became
gangrenous.

Isaacs1 reports on the alkali treatment of acute methyl-alcohol poison-
ing. If the patient is not comatose and is received within twelve
hours after taking the wood alcohol, it is well to pass a stomach tube
and wash out the contents with a 1 or 2 per cent solution of sodium
bicarbonate in warm water, as experience has shown that some of the
alcohol is excreted into the stomach. Three or four ounces of a 50
per cent solution of magnesium sulphate are then poured in through
the tube and left in the stomach. Sometimes an hour or more after
washing out the stomach the patient will vomit a considerable amount
of food debris, having a marked odor of methyl alcohol. The patient
should be kept warm if his temperature is low, and is given 3 gm. of
sodium bicarbonate, with about 250 cc of water every two hours, for
six doses, being awakened for his medication if asleep. A whiff or two
of aromatic spirit of ammonia will serve to awaken the patient sufficient
to make him swallow. The dose of bicarbonate may be doubled
without apparent ill-effects. Following the initial six doses the patient
is given 3 gm. of sodium bicarbonate in a glass of water, three times
daily one hour before meals, until the symptoms have disappeared.
A safe guide to the dosage is to keep the fresh urine alkaline to methyl
red. Fluids are forced and the diet should be a liquid one until the
acute symptoms have ceased.

If the patient is comatose, or if the cyanosis is marked,. with depres-
sion of respiration, it is well to wash out the stomach first. Under
these circumstances, or if medication by mouth is not retained, 1000
cc of Fischer's solution (sodium bicarbonate, 0.37 per cent; sodium
chloride, 1.4 per cent at 99° F.) is given slowly intravenously. Isaacs
also gives Fischer's solution in cases in which there is any doubt. No
ill-effects have been noted from the treatment. If there is time and,
at the same time, there is evidence of venous congestion and embarrass-
ment of the right heart, it is advisable to perform a venesection to the
amount of 100 to 300 cc before giving the intravenous injection. The
injection may be given in full or half given later. A second injection
on succeeding days is, as a rule, not necessary.

Spinal puncture may be performed if there is much restlessness or
signs of cerebral compression. After Fischer's solution there appears
to be a dehydration of the nervous tissue, with an increase of the spinal
fluid. The breathing usually improves rapidly, the mental state clears,
and in from six to twelve hours the cyanosis has virtually disappeared.
The eye signs also improve rapidly, the blurring of vision disappearing
in from twelve to twenty-foflr hours, although in some cases it may take
slightly longer. Abdominal tenderness likewise soon disappears.

The patient should be kept in bed until the cyanosis has disappeared
and the mental confusion has cleared up. The average stay in the

1 Ohio State Medical Journal, July, 1921.

ANTIMONY 315

hospital was five days, with treatment for two or three days. Patients

should be ordered to return at intervals to note whether then ■ has beeD
any change.

Allonal. Allonal is composed of allyl-iso-propyl-barbituric acid and
amidopyrin. Its dose is usually 2 to '-\ gr. in tablet form; as much as
four tablets have been given. Burns1 recommends this new drug and
states that it is administered orally in the form of 2§-grain tablets.
I lis experience shows that one tablet acts well as a sedative, two tablets
as a hypnotic and that two to four should be used when an analgesic
effect is desired; this dose may be repeated in one to two hours where
required. The action seems to be well sustained and free from any
unpleasant after-effects.

Burns thinks it is safe to conclude that allonal is a remedy of real
value for controlling insomnia and pain, and that it will enable us
to get along with less of the narcotic pain-allaying remedies. Jt gave
better results than morphine in many cases, and in others better than
morphine and hyoscyine combined.

Ammonium Chloride. The use of this drug in the symptomatic
treatment of tetany in children is recommended by Freudenberg and
Gyorgy.2 It averts the acute danger and time is gained in which to
bring about a permanent change in the condition by means of cod-liver
oil and quartz lamp irradiation. The drug is given internally in doses
from 3 to 7 gm. per day. In some instances the administration was
kept up for ten days. The authors state that ammonium chloride is
preferable to calcium chloride as it is more pleasant to take.

Antimony. This drug has established itself as the method of choice
in the treatment of bilharziasis. Pavy3 reports the case in which he em-
ployed tartar emetic intravenously. The solution used consisted of 0.06
gm. of tartar emetic dissolved in 5 cc of physiologic salt solution. This
was injected slowly into a vein well below the elbow-joint. The initial
dose in all cases was 2.5 cc of the solution (0.5 gr. of tartar emetic).
Patients who showed a good tolerance for the drug were worked up to
10 cc 2 gr.) in from four to six injections and kept on this dose with
occasional remissions to a smaller dose. In some cases the maximum
dose had to be approached more gradually. Doses of 0.18 gm. were
given in 2 cases, but as the majority of the patients had moderately
severe attacks of coughing with nausea and occasional vomiting after
giving 0.12 gm. it was not thought advisable to push the dose further.
The average amount given was 1.8 gm. (27 gr.). This usually meant
that by the end of the course no ova were found in the urine for four
weeks. The injections were given daily at first, later on— three days
a week. Xo local effects followed the injections unless some of the fluid
escaped. The same vein can be used repeatedly. One of the most
interesting and constant features of the treatment was the rise in the
percentage of eosinophile cells which occurred.

The patients were not confined to bed nor dieted. Neither did they
receive any other form of treatment before, during or after the injection.

1 New York Medical Journal, April 19, 1922.

2 Medizinisch-klinische Wochenschrift, February 25, 1922.

3 Medical Journal of Australia, July 30, 1921.

316 LANDIS: THERAPEUTIC REFERENDUM

Apocynum Cannabinum. Apocynum cannabinum, or Canadian hemp,

is a drug which has been employed for a century in the treatment of
heart disease. Some observers believe it is especially valuable in
dropsical conditions associated with heart disease. Marvin and White,1
in a clinical study of this drug conclude that the fluidextract has, in
some degree, a digitalis-like action in cases of heart disease with auricu-
lar fibrillation. They report 1 case of auricular flutter, in which the
administration of apocynum changed the condition to auricular fibrilla-
tion. The drug was withdrawn and two days later the rhythm was
normal. In their opinion the usefulness of the drug in the treatment
of heart disease is markedly limited because of the discomfort, nausea
and vomiting, which invariably follow its administration in doses suffi-
ciently large to affect the heart.

Marvin and White also studied the effects of convallaria majalis, or
lily of the valley. They conclude that neither apocynum nor conval-
laria can be used as substitutes for digitalis. In their experience digi-
talis has been characterized by quicker action, more pronounced effects,
less discomfort and more prolonged improvement than are seen follow-
ing either of these drugs. They, therefore, state that as a result of
their observations, neither of these drugs has a place in the rational
treatment of heart failure.

Bacillus Acidophilus. Rettger and Chaplin2 have published a paper
on the therapeutic uses of this organism. The following groups were
treated: (1) Chronic constipation with the symptoms of so-called
autointoxication and other accompanying pathologic conditions, some
of them acute, 20 cases; (2) chronic diarrhea following an attack of
bacillary dysentery, 2 cases; (3) colitis, at times bloody, and more or
less mucous, 3 cases; (4) sprue, 2 cases; (5) dermatitis (eczema), 3 cases.

In treating the constipation cases it was the aim to obtain a pro-
nounced transformation of the bacterial flora of the intestines in the
shortest period of time. As lactose has a marked laxative effect when
taken internally in sufficient amount, persons having a history of
obstinate chronic constipation at first usually receive 1 quart of acido-
philus milk plus 100 gm. of lactose daily. The lactose was added to
the acidophilus milk in the flask and the contents thoroughly shaken.
The patients were instructed to take the daily supply in three equal
portions, one in the forenoon, another in the afternoon, and the third
immediately before going to bed, and in every instance at least two
hours before and after meals. There were no regulations as to diet,
except to warn the patients to abstain from food, which, by experience
or training, they knew to be injurious.

If, in the course of three or four days, the constipation was not
relieved except by an enema, which was advised when the condition
of the subject made it absolutely necessary, the daily amount of lactose
was increased by 25 to 50 gm. If, on the other hand, peristalsis became
too active and diarrhea resulted from taking the full amount (1 liter
of acidophilus milk and 100 gm. of lactose), the quantity of lactose

1 Journal of the American Medical Association, December 21, 1921.

2 Archives of Internal Medicine, March, 1922.

BARBITAL 317

was reduced by 25 to 50 gm. \n a few instances the volume of milk
was reduced to 500 cc, with or without a reduction in the amount of
lactose.

In the treatment of the diarrheal cases (including those of colitis and
sprue) 100 cc of acidophilus milk without any added milk sugar were
given. Persons who could not take other food in any form retained
acidophilus milk and complained of no ill-effects.

In the 3 cases of eczema the treatment was discontinued in 2 of them
before any definite results were obtained. The third patient responded
completely and for five months has been free from the trouble which
had been a source of constant annoyance for twelve years.

Chaplin and Wiseman1 report on the use of acidophilus milk in the
treatment of constipation. Living twenty-four-hour cultures were
administered daily. With but few exceptions, 500 cc of the milk pro-
duct reinforced with 100 gm. of lactose were ingested each day in two
equal doses. At no time was any special or modified diet prescribed
and no laxatives were given. In most of the cases the response Was
prompt, and daily evacuations took place. In some cases the influ-
ence of 500 cc of the acidophilus milk was less pronounced at the start,
but quite an appreciable difference was obtained when the amount
of the milk and added lactose were doubled. Within a few days after
the ingestion of the acidophilus milk and added lactose, daily stools
were obtained and a transformation of the flora took place, in which
the usual mixed bacterial types gave way to a more simplified flora
largely represented by the Bacillus acidophilus.

Two additional articles on the use of Bacillus acidophilus express
divergent opinions. Bassler and Lutz2 obtained negative results.
They state that no immunity, local or general, of the real bacterial
offenders was accomplished, and all that was accomplished was a
simulation of the intestinal toxemia for the time being. The same
result can be accomplished just as well by the use of several teaspoon-
fuls of lactose taken during the day. This simple procedure will
stimulate an enhancement of growth of Bacillus acidophilus resident in
the intestinal canal of all human beings in only a slightly longer time,
and at a cost that is far less to the patient.

Kopeloff and Cheney3 subjected a series of psychotic patients suffer-
ing from chronic constipation to this treatment. They state that
relief from chronic constipation and diarrhea was secured by the inges-
tion of Bacillus acidophilus milk and lactose in mentally normal and
psychotic patients. Five of the psychotic patients receiving such
treatment showed no improvement in their mental condition during
the period of treatment; in 2 others improvement was slight, but no
greater than might have been expected without the treatment.

Barbital (Veronal). Among 286 cases of acute poisoning, Boenheim4
states that barbital poisoning occurred in 5.7 per cent.
The drug had been taken with suicidal intent, and 5 died. All of

1 Boston Medical and Surgical Journal, November 24, 1921.

2 Journal of the American Medical Association, August 19, 1922.

3 Ibid. * Medizinische Klinik, October 16, 1921.

318 LANDIS: THERAPEUTIC REFERENDUM

these cases had taken over 10 gm. Boenheim states that up to this
amount the prognosis is not grave and, even with larger doses, recovery
may occur. The main symptom is drowsiness to the deepest coma.
The temperature is unstable. The main point of attack is the periph-
eral circulation, the drug apparently paralyzing the walls of the capilla-
ries so that vasomotor disturbances are constant. A characteristic
feature is the alternate dilating and contracting of the pupils.

There are no symptoms referable to the gastro-intestinal tract. The
abdominal reflexes are absent, while the tendon reflexes are retained
or exaggerated. The greatest danger in these cases is the develop-
ment of pneumonia, which almost invariably proves fatal. If the
patient survives two days, recovery occurs unless pneumonia occurs.
There is no known antidote. Washing out the stomach promptly and
the use of stimulants are the usual means employed to combat the
poison.

Betanaphthol. This drug is recommended by Cains and Mhaskar1
as a vermicide. They state that the drug is safe up to a dose of 60 gr.
It acts powerfully on ankylostomas and necators. Up to 40 gr. it may
be given in a single dose, and no after-purge is required. Beyond 40
gr. the drug may be given in two or three portions. It also is an effec-
tive ascaricide.

Bromides. The use of bromides for the control of nervous excita-
bility is largely practiced and they are generally regarded as being
harmless. Hunt2 states that there are certain types of epilepsy in
which the use of bromide aggravates both the irritability and restless-
ness preceding the seizure as well as the depression following. Patients
suffering from arterial changes are peculiarly susceptible to bromide,
and alcoholics are prone to develop bromide intoxication. In heart
cases even small doses of bromide may depress and enfeeble the heart,
and, if long continued, give rise to mental symptoms akin to paresis.
Hunt believes that the use of bromides in mental disease may mask the
symptoms just as thoroughly as does opium in surgical conditions.

Calcium. The use of the calcium salts in the treatment of tuberculosis
is frequently advocated. Moendl3 has made a second report on the
intravenous use of calcium chloride. In patients with a severe hemop-
tysis he gives 5 cc of a 10 per cent solution of calcium chloride every
eight hours until the bleeding stops and continues it once a day for
several days thereafter.

He also employs the drug routinely. He has given a total of 4000
intravenous injections to 250 patients. The injections are given every
day or second day to a total of twenty and then suspended for a week
or two. He claims for this method the subsidence of the subfebrile
temperature in a number of rebellious cases and also that the effect on
the cough, expectoration, night-sweats and shortness of breath was
decidedly favorable.

If injected subcutaneously, or into a muscle, the drug causes a local

1 Indian Journal of Medical Research, July, 1921.

2 New York State Journal of Medicine, July, 1921.

3 Zeitschrift f . Tuberculose, November, 1921.

CARBON TETRACHLORIDE 319

necrosis. Used intravenously, Moduli states that he has had no local
disturbance for several years.

As already stated, calcium is advocated from time to time in the
treatment of tuberculosis, but the generally accepted opinion is that
it is of no value.

For many years there has existed a tradition that those who work with
lime are immune to tuberculosis, or, if they have the disease, become
cured. Tweddell1 states that manufacturers of lime and gypsum
informed him that their employees were apparently immune to tuber-
culosis, lie claims that the fine particles of lime and gypsum are
carried, by inhalation, into the lungs. The lime coming into contact
with the moist tissue of the lungs forms calcium hydroxide, which
acts as a caustic and antiseptic and is then absorbed. Gypsum acts
in the same way.

Tweddell also cites observations and references to show that calcium
added to the food not only helps prevent tuberculosis, but also favors
the healing of wounds and fractures. In this connection, it might be
stated that extensive studies on calcium metabolism in tuberculosis
has failed to show that it exerts any favorable influence on the disease.
Camphor. An oil solution of camphor, according to Rao,2 is made
by first dissolving the camphor in ether and then adding the solution
to sterilized olive oil. The solubility of camphor in ether is 12 to 7.
The solution must be quite clear before it is added to the oil. In the
treatment of sciatica, Rao used a solution containing 0.5 gr. of camphor
to each cc. The first dose was 3 cc, and injected with the usual anti-
septic precautions. The injection was made deep into the gluteus
muscle of the affected side and slightly away from the nerve.

As olive oil is fairly heavy, with a large "drop," it is necessary to
choose a needle with a large caliber. The injections were repeated
every day until six were given, the increase being 1 cc up to 6 or 7 cc.
The patient reported by Rao obtained some relief from the third injec-
tion and, although previously bed-ridden and suffering great pain, was
able to walk and complained only of some numbness in the limb. The
sharp, agonizing paroxysms of pain ceased. Four days after the last
injection there was a recurrence of slight pain which was relieved by
two injections of 6 cc each. These final injections apparently stopped
the pain and the patient was able to be about and attend to her needs.
Carbon Tetrachloride. A year ago Hall3 concluded, from experiments
on dogs, that carbon tetrachloride was more effective against hookworms
than any of the drugs commonly used, even when these are used in
such combinations as chloroform and chenopodium. He found it safe,
giving rise to no evident symptoms or postmortem lesions, even in
doses five times as large as are necessary to give dependable efficacy
against hookworms. Only a pure and carefully refined carbon tetra-
chloride should be used. The drug is also very effective for removing
ascarides, although somewhat inferior to chenopodium in this respect.

1 Medical Record, January 28, 1922.

2 Madras Medical Journal, September-October, 1921.

3 Journal of Agricultural Research, April 15, 1921.

320 LANDIS: THERAPEUTIC REFERENDUM

In common with other anthelmintics, it will remove whipworms,
but is of no value against tapeworms. In a later communication, Hall1
records further experimental work on the toxicity of the drug in mon-
keys. It would seem from these experiments that the drug could be
used safely in man. Hall states that carbon tetrachloride has the
advantage of being much cheaper than thymol or chenopodium, and
can be purchased almost anywhere at any time. A great advantage it
possesses is that it does not depress unstriated musculature or lessen
peristalsis so far as has been studied. This fact would permit of an
immense saving by the omission of a purgative in carrying on hook-
worm campaign involving millions of people.

Leach2 has made a preliminary report of 14 cases of hookworm
disease, in which he employed carbon tetrachloride. In all but 1 case
the only symptoms complained of were slight giddiness and a sensation
of weight in the stomach. In 1 case diplopia and nausea were experi-
enced. Little effect was produced on the heart action. Leach con-
cludes that carbon tetrachloride given in 10-ec doses to a man pro-
duced no ill-effects as far as could be seen on microscopic examination.
Twelve cubic centimeters of carbon tetrachloride removed all hook-
worms and ascarides, but apparently had little effect on trichurids and
oxyurids.

Chaulmoogra Oil. The success that has been met with in the treat-
ment of leprosy with chaulmoogra oil has naturally led investigators
to the hope that tuberculosis might also be benefited, inasmuch as both
diseases are due to an acid-fast organism. It would appear, from the
work of Walker and Sweeney,3 that the unsaturated fatty acids of
chaulmoogra oil have a specific germicidal action upon acid-fast bacte-
ria, being one hundred times more powerful than phenol. This explains
their beneficial and even curative influence in leprosy, and awakens the
hope that they will prove effective in tuberculous affections.

The great difficulty with chaulmoogra oil is that it is so repugnant
to the taste and so disturbing to the gastro-intestinal tract that its
internal administration has been unsatisfactory, while its irritating
character makes it unsuitable for subcutaneous injection. Thus far,
only two of the peculiar groups of fatty acids present in chaulmoogra
oil have been isolated, but chemists are at work on the subject. It
may also be possible to construct these acids, which are found not only
in chaulmoogra oil, but also in cod-liver oil, synthetically, and to
modify and improve them with a view of increasing their therapeutic
efficiency.

Some of the ethyl esters of the mixed fatty acids have been used
and are free from the disadvantages of the oil itself, when given intra-
muscularly. Rogers has employed the so-called gynocardates with
benefit.

In a study of the gynocardate derivatives, Chara4 has shown that

1 Journal of the American Medical Association, November 21, 1921.

2 Ibid., June 10, 1922.

3 International Journal of Surgery, 1921.

4 Japan Medical World, January, 1922.

CHAULMOOGRA OIL 321

sodium gynocardate, gynocardate ethylesterm and gynocardate idio-
ethylester produce central paralysis. The action is most marked with
sodium gynocardate and least so with the ethyl ester. On bloodvessels
all three drugs have a contracting action.

A most interesting and important contribution on the use of chaulr
moogra oil in the treatment of tuberculosis has been made by Lukens.3
lie employed the drug in tuberculous laryngitis. Lukens found that the
remedy was best applied by means of intratracheal or intralaryngeal
injection. One cubic centimeter of the oil, usually 10 or 20 per cent,
in liquid petrolatum or olive oil, is drawn up in a Luer syringe armed
with a metal Eustachian catheter. While the patient holds the tip
of the tongue, wrapped in a paper napkin, between the index finger
and the thumb of the right hand, the syringe tip is introduced, guided
by the throat mirror, into the pharynx (not the larynx) above and
behind the epiglottis, care being taken not to touch any portion of the
mouth or throat. Two-thirds of the contents of the syringe is dis-
charged, drop by drop into the trachea while the patient breathes
quietly. The remainder is then dropped on the cords while the patient
phonates. In this way, cough following injection is very slight and
often entirely absent. When present it comes on a few minutes after
the injection and only lasts a minute or so.

Lukens concludes that the chief value of the oil is in the relief of
pain and dysphagia and that this is continuous, in contradistinction
to that produced by cocaine. The treatment is not unpleasant or dis-
tressing, is without untoward reactions in the larynx, and can be used
without previous cocainization. While the improvement is not all
that could be desired, it seems better than that obtained with other
drugs. I have knowledge of several very distressing cases in which
this use of chaulmoogra oil gave great relief and even offered a hope of
curing the local lesions.

An experimental study of chaulmoogra oil in the treatment of tuber-
culosis has been made by Culpepper and Ableson.2 Forty-eight guinea-
pigs were divided into five groups: (1) 12 pigs were inoculated with
human-type bacilli and left without further treatment as controls;
(2) 12 pigs were similarly inoculated and divided into groups of 3
each, which were given intraperitoneal doses of the acid sodium salts
of the four fractions A, B, C and D of acids of chaulmoogra oil; (3) 8
pigs were left as entirely untreated controls; (4) 12 non-tuberculous
pigs received increasing amounts of A, B, C and 1) fractions in a toxicity
test.

These results showed that 1 per cent solutions of the acid sodium
salts of the four fractions are least irritating and are readily absorbed
from the peritoneum. No pathologic findings could be attributed to
the drug. A bactericidal action on tubercle bacilli in 1 to 10,000 dilu-
tion was found. Of the 12 control pigs all died except 1. Of the 12
treated pigs, only 1 died. The others were killed for comparison,
1 whenever a control animal died. A marked difference in pathologic

1 Journal of the American Medical Association, January 28, 1922.

2 Journal of Laboratory and Clinical Medicine, May, 1921.

322 LANDIS: THERAPEUTIC REFERENDUM

findings was observed, the advantage being in favor of the treated
pigs. The treated animals showed an average gain of weight of 49 gr.
over the ones not treated.

Leonard Rogers,1 in an experimental study of tuberculosis treated
with derivatives of chaulmoogra oil, especially sodium morrhuate,
sodium gynocardate and hydrocarbic acid, obtained negative results.
He points out, however, that these animal infections are equivalent to
acute general tuberculosis in man, so that the failure in such cases does
not prove the drugs to be useless in the more chronic forms of tubercu-
losis, which form the great majority of human cases. Rogers concludes
that these drugs are worthy of further trial in the more chronic forms
of the disease, and especially in lupus and surgical tuberculosis, where
any changes will be visible and easily observed.

Harper2 reports on 200 patients who are undergoing treatment for
leprosy by intravenous injections of chaulmoogra oil. Since the treat-
ment was started over 26,000 injections have been given. No serious
effects have occurred, except for two subcutaneous abscesses due to
faulty technic. Both healed promptly. The dose must be adjusted
for each patient, as the toleration varies considerably. The tempera-
ture chart alone is no guide to dosage. Reactions may consist of
tachycardia, fever and a blotchy, red, raised eruption, sometimes
accompanied by swelling of the nodules and infiltrations, which are
then completely, or partially, absorbed. These reactions are seldom
very disturbing, and in most cases improvement takes place without
the reaction being severe enough to be noticed.

Thirty-eight patients have been under treatment for periods of up
to eleven months. Twenty-eight have improved, 1 died of influenza,
3 have become worse and in 6 there has been no change. Previous
reports on the treatment of leprosy have shown that the oil or its
derivatives must be administered for periods of a year or more before
a cure can be effected.

Its use in tuberculosis must also be prolonged if the analogy between
the two diseases in this respect is correct.

A note in the Army Medical Bulletin for January 18, 1922, sounds
the following warnings: "The United States Public Health Service
has felt it necessary to deplore the too optimistic and extravagant
claims recently appearing in the newspapers in regard to the curative
effects of chaulmoogra-oil derivatives on leprosy. While the use of
the oil and its derivatives has resulted in a considerable number of
apparent cures, it is as yet too soon to tell whether these will be per-
manent.

The ethyl esters of chaulmoogra oil, the use of which has largely
supplanted that of the oil itself, constitute a most valuable agent in
the treatment of leprosy. In treating young persons and those in the
early stages of the disease the improvement has been rapid and strik-
ing; in older persons and older cases it is less so; of the cases paroled
from the leprosy stations in the Hawaiian Islands, so far about 8 per

1 Lancet, June 4, 1921.

2 Journal of Tropical Medicine and Hygiene, January 2, 1922.

COD LIVER OIL 323

cent have developed and returned for treatment. This was to be
expected; and, on the whole, the results have been so favorable as to
make treatment of the disease hopeful. But only time can tell."

Chinosol. The use of an ointment of chinoso] in the treatment of
erysipelas is reported by Lusk.1 The formula for making the oint-
ment is as follows: Cold, sterile water, 0.5 dr.; add and dissolve
powdered ehenosol, 10 gr.; then add sodium chloride (reagent), 4 gr.
Rub up, first with lanolin, 0.5 oz., finally incorporating petrolatum,
0.5 oz. This ointment, while applicable for use in the treatment of
erysipelas on any skin area of the body, was generally used for all
parts only in children, its use in adults being generally limited to the
face and ears.

Cocaine. In the course of ten weeks' time Pulay2 encountered 5
eases of erythema in the region of the fifth nerve, resulting from the
abuse of cocaine. In 1 case there had been also an attack of convul-
sions and unconsciousness, with a rapid pulse and widely dilated pupils.
All of these patients confessed that they had been trying the drug. In
some other cases the rash developed after the use of the drug by a
dentist. In 1 of these cases there was an epileptic seizure the same
evening, and the erythema developed the next morning.

In some experimental work Mayer3 injected morphine before or
after cocaine in frogs. The control frogs, which were injected with
cocaine, alone survived, while all of those receiving both morphine and
cocaine died. Mayer believes that this shows that the morphine
enhances the toxic action of the cocaine, and that the custom of inject-
ing morphine before using cocaine is dangerous. He found, further-
more, that calcium chloride seems to inhibit the action of cocaine.
A small dose of cocaine stimulates the frog heart, while a large dose
arrests its action, but calcium chloride starts it to beating again. When
the calcium chloride was given first the cocaine had no toxic action.
Mayer also found that in frogs, while calcium salts arrest the toxic
action of cocaine, potassium salts exaggerate it.

.Cod-liver Oil. This substance is now recognized as being practically
a specific in the treatment of rickets. While it has been used for a
long time in this condition it is only recently that its specific value
has been demonstrated. The proof of this has been furnished by
Park and Howland.4 They have studied the bone changes by means
of the roentgen rays. Their results in many cases have been so con-
sistent that they feel justified in stating definitely that cod-liver oil
brings about a change in the bones, which, if the diet is not too faulty,
amounts to complete cure. The change is not noticeable at once, but
is readily demonstrated in nearly all cases by the end of a month. By
the end of two or three months so much infiltration with salts has
taken place that the extremities of the bones, except for deformities,
are practically normal, and only differences in the finer architecture

1 Annals of Surgery, February, 1922.

2 Medizinische Klinik, March 26, 1922.

3 Schweizerische med. Wochenschrift, August 18, 1921.

4 Bulletin of Johns Hopkins Hospital, November, 1921.

324 LANDIS: THERAPEUTIC REFERENDUM

of the ends of the bones indicate the previous existence of a rachitic
process.

The work of Park and Howland and that of others who have reported
most excellent clinical results make it reasonably certain that rickets
can be cured entirely.

Corpus Luteum. In previous numbers of Progressive Medicine we
have quoted the favorable results obtained by J. C. Hirst in the treat-
ment of the vomiting of pregnancy with corpus luteum.

King1 does not share Hirst's enthusiasm. The mild cases, he states,
do respond, but the same can be said of any line of treatment. King
states that in his experience ovarian extract, horse serum, thyroid
extract and epinephrin do not measure up to the expectations aroused
by some articles in the literature. In his opinion the best results are
obtained in the toxemia of pregnancy by the use of sedatives, colonic
irrigations of sodium bicarbonate solution, forced fluids, glucose, etc.,
and he furthermore believes that therapeutic abortion should not be
too long delayed in refractory cases. Pinard's dictum that we should
abort when the pulse is persistently above 100, while, in King's opinion,
unduly radical, is a good guide, especially when considered in con-
nection with the general condition of the patient and laboratory studies
of the blood and of the urine.

Creosote. Thorling2 reports a case of poisoning with creosote in an
infant, aged two months. The creosote had been given by mistake for
a laxative. The symptoms resembled very closely those of Winckel's
disease. The amount taken was not over 1 gm. at most, but the child
died in two and a half days. There was little evidence of any local
caustic action, the mouth clearing up readily. There was slight vomit-
ing at first but no intestinal symptoms at any time.

The main symptoms were hemolytic jaundice, hemoglobinuria and
a leukocytosis. Twelve hours after the ingestion of the drug the red
cells numbered 1,800,000 and the leukocytes 25,000. Thorling sug-
gests that the possibility of a chemical irritant should be thought of in
children presenting obscure clinical pictures, instead of assuming them
always to be infectious in origin. This is particularly important
because of the susceptibility of young children to chemicals which
have a destructive action on the blood.

Dibromine. This is a new bromide compound which possesses con-
siderable germicidal power. It is a crystalline substance, white in
color, odorless except for a faint suggestion of bromine, and does not
possess an objectionable taste. Furthermore it makes a water-clear
solution, which does not stain the skin or clothing.

Saint-Pierre3 has employed the drug in solution in the treatment
of a series of 225 cases, including metritis in young women, tubal catarrh,
leucorrhea and vulvar yruritis. In each case the patient was given
daily douches of two pints of dibromine solution, 1 to 15,000. Soon

1 Journal of the American Medical Association, February 18, 1922.

2 Upsala Lakareforenings Forhandlingar, September 1, 1921; Abstract, Journal
of the American Medical Association.

3 Therapeutic Gazette, June, 1922.

DIET 325

after these douches were applied the character of the discharge was
changed to a less purulent condition and a considerable loss in odor.
The treatment also had a cleansing effect and showed a marked influ-
ence upon the bacterial flora of the parts irrigated, with an absence of
any trace' of irritation.

A great advantage also lies in the fact that the solution is colorless
and docs not stain the undergarments.

Diet. The World War brought about a condition of affairs regarding
the food supply that made the subject of dietetics of universal interest.
The result has been that for the past four or five years the medical
and lay journals have contained a large number of articles on the sub-
ject. One noteworthy effect has been that physicians have taken a
more keen interest in a subject which is of the most vital importance
in dealing with disease.

McCarrison,1 who has previously contributed articles on the effect
of faulty food in relation to gastrointestinal disorders, made this the
subject of the Mellon Lecture, held under the auspices of the University
of Pittsburgh. From a review of the dietetic habits of primitive
people and experimental observations on monkeys, he believes, he is
justified in drawing certain broad conclusions:

1. The health of the gastro-intestinal tract is dependent on an ade-
quate provision of vitamins. The absence of growth vitamins is
capable of producing pathologic changes in the tract, which frequently
assume the clinical form of colitis. This observation is of the highest
importance in view of the frequency with which this malady is encoun-
tered at the present day. Deficiency of vitamin C is especially con-
cerned in the production of congestive and hemorrhagic lesions in the
tract, and evidence of these may be found in animals which have not
exhibited during life any of the clinical evidences of scurvy in note-
worthy degree. A state of ill-health of the gastro-intestinal tract may
thus be a prescorbutic manifestation of disease due to insufficiency of
this vitamin, especially when associated with an excess of starch or
fat or both in the food.

2. The disorder of the gastro-intestinal tract consequent on vitamin
deficiency is enhanced when the food is ill-balanced.

3. The pathologic processes resulting in this situation from deficient
and ill-balanced foods are: (a) Congestion, necrotic and inflammatory
changes in the mucous membrane, sometimes involving the entire
tract, sometimes limited areas of it. (6) Degenerative changes in the
neuro-muscular mechanism of the tract, tending to dilatation of the
stomach, following of areas of small and large bowel, and probably also
to intussusception, (c) Degenerative changes in the secretory elements
of the tract; these changes are such as must cause grave derangement
of digestive and assimilative processes, (d) Toxic absorption from
the diseased bowel as evidenced by changes in the mesenteric glands.
0) Impairment of the protective resources of the gastro-intestinal
mucosa against infecting agents, due to hemorrhagic infiltration, to

1 Journal of the American Medical Association, January 7, 1922.

326 LANDIS: THERAPEUTIC REFERENDUM

atrophy of the lymphoid cells, and to imperfect production of gastro-
intestinal juice; this impairment not only results in infections of the
mucous membrane itself, but also permits of the passage into the
blood stream of microorganisms from the bowel. (/) It is to be empha-
sized that the pathologic changes found in the gastro-intestinal tract
arc more marked in some individuals than in others; and that, while
all of them may occur in one and the same subject, it is usual to find
considerable variation in the incidence of particular lesions in different
individuals.

The vitamin C referred to by McCarrison is found principally in
lime and lemon juice, orange juice, tomatoes, sprouted seeds and
fresh unpasteurized milk. The last-mentioned is especially important
in furnishing the growth vitamin.

McCarrison states that there are three distinct duties to be per-
formed: (1) To instruct the masses as to what to eat and why they
eat it; (2) to apply the results of our science to the production of natural
foods in abundance and to their widespread and cheap distribution,
rather than to the erection of institutions for the treatment of maladies
due to their want; (3) and most important, ardently to pursue our
investigations and the acquirement of knowledge.

An acute form of food infection is now recognized to be due to con-
tamination with the bacillus of Gartner (Bacillus enteritidis). Rosenau
and Weiss,1 in reporting a small epidemic, give an excellent review of
the subject.

In 112 outbreaks studied in Great Britain there were some 6190 cases,
with 94 deaths, a mortality of 1.5 per cent.

Most of the cases occur in summer time. As the bacilli responsible
for food infection grow in the food before it is eaten, the temperature
is a very important factor. The greater multiplication of these bac-
teria in hot weather also increases the opportunities of transmission
of infection through flies and other means.

The great majority of outbreaks of food infections are due to meat
foods; hence, the frequent use of the term "meat poisoning" in this
connection. Of the 112 British outbreaks, in 21 the vehicle was a
non-flesh food. Pork or beef accounted for 68 per cent of the British,
and 61 per cent of the continental outbreaks. Instances of this form
of food infection are rare in this country.

The symptoms of food infection are essentially those of an acute
gastro-intestinal irritation, namely, nausea, vomiting, abdominal pain
and diarrhea. The condition is distinctly different, therefore from
botulism, in which there is an absence of gastro-intestinal symptoms.
The onset in food poisoning is usually sudden and may be ushered
in with headache and a chill. The abdominal pain is frequently the
first symptom, and may be griping and severe. The diarrhea usually
consists of repeated bowel actions, which, as a rule, are offensive. Later
in the attack the stools become more watery and of a green color.
Faintness, muscular weakness and prostration may be quite marked.

1 Journal of the American Medical Association, December 17, 1921.

DIET 327

Thirst is always present and there is almost always some lexer, usually

102 to 103° F. In sonic cases restlessness, muscular twitchings and
drowsiness may occur.

The severity of the symptoms varies greatly in different outbreaks
and even in the same outbreak. The symptoms vary with the dose,
that is, with the number of bacteria ingested with food. The severity
doubtless depends on the virulence of the particular strain of bacteria
concerned, the length of time it had to grow upon the food before
consumption and the temperature of growth.

The incubation period ranges from six to twelve hours, but may be
delayed for as long as seventy-two hours.

The diagnosis depends on the history of exposure to the suspected
food: Symptoms suggestive of food poisoning; isolation of the infect-
ing organism from the suspected food, and also from the blood, urine,
feces or viscera of the patient.

The outbreak reported by Rosenau and Weiss occurred in a group
of medical students. There were 25 and of this number IS, who had
partaken of the spread, were made ill. All of these who had eaten
bread pudding had symptoms, whereas those who did not partake of
this food remained free from symptoms. The evidence was, therefore,
strongly in favor of the pudding being the offender. Analysis of the
pudding revealed the presence of a mildly virulent Bacillus enteritidis.

The symptoms displayed by the students were quite characteristic,
namely, diarrhea, somewhat offensive stools, nausea and vomiting.
The temperature rose in most of the cases to 102° or 103° F., but rapidly
fell to normal in from twenty-four to forty-eight hours. One of the
patients complained of some numbness in his fingers and contraction
of the muscles of the hand and 1 had contractions of the muscles of the
face.

Botulism. This form of food poisoning continues to be reported.
The classic source of botulism is sausage; hence, the name "botulism,"
from the term " botulus," a sausage. It is now known, however, that
botulism occurs from the eating of other foods which have become
contaminated by the Bacillus botulinus. The disease first attracted
attention in this country from outbreaks following the eating of ripe
olives. Since then other food products, usually canned vegetables,
have been the source of the trouble. The reason for this has been
pointed out in an editorial article.1 An analysis of the reported out-
breaks has shown that certain articles of food are implicated more
frequently than others. First come the foods preserved by heat.
Since the air is expelled in the heating process, and since the containers
of these foods must be hermetically sealed, it is easy to see that the
anaerobic conditions so produced provide particularly favorable oppor-
tunities for the growth of any Bacillus botulinus spores that have sur-
vived the heating process. As with other bacteria, growth of the
botulinus spores is hindered by a high concentration of sugar or brine,
or by a marked acid reaction. Botulism from the eating of jam or

1 Journal of the American Medical Association, July 1, 1922.

328 LANDIS: THERAPEUTIC REFERENDUM

candied fruits or from brine-pickled green olives is unknown; indeed,
the disease has been very rarely attributed to the use of any sort of
preserved food.

Inasmuch as botulism is so frequently traced to the eating of canned
foods imperfectly sterilized, it is not surprising that a relatively high
proportion of the outbreaks should have been traced to foods canned
in the household, where facilities for maintaining cooking temperature
considerably above the boiling-point are not always readily available.
Even commercially canned vegetables are not free from the danger,
as several outbreaks have followed the use of such products. Spinach
seems to be especially hard to secure the adequate amount of heat
penetration to effectively kill the botulinus spores.

Although the actual number of deaths in a year from botulism is
not very large, probably considerably less than 100 in the whole United
States, its high case mortality (more than 60 per cent) and our present
therapeutic helplessness combine to urge intensive study of each out-
break.

Vedder1 reports a small outbreak following the eating of sausage.
Of the 6 men infected, all had eaten the sausage raw, while those who
ate it cooked escaped. The sausage had been purchased on Saturday
and kept in an ice-box until the following Monday. It was known
that the allowance of ice was insufficient to preserve meat satisfactorily.
All of the infected men presented the characteristic symptoms, namely,
difficult swallowing, blurred vision, diplopia, dizziness and weakness
of the legs.

Colver,2 in commenting on 5 cases of botulism, directs attention to
the fact that it is essentially a toxic encephalitis affecting the
pons and medulla, and with a rapid course. Epidemic encephalitis,
with which it may be confused, affects, as a rule, the cortex, the
meninges or the basal ganglia of the upper cranial nerves and pursues
a more deliberate course than botulism.

Beal3 reports a particularly severe outbreak following the eating of
a meal of canned salmon and canned spinach. Within from twelve
to twenty-four hours 9 persons, all of whom had partaken of this meal,
and all of whom had certainly partaken of the spinach developed typical
symptoms of botulinus poisoning. All persons who ate some of the
spinach developed symptoms, while no one in the hospital became
ill who had not eaten the spinach, and there were 4 or 5, though they
did eat the salmon.

Wells4 reports a single case in which canned spinach was the offender.

The relative frequency with which canned spinach has been impli-
cated led the Bureau of Chemistry of the Bureau of Animal Industry,
United States Department of Agriculture, to study the subject. Kos-
ner, Edmondson and Giltner5 examined bacteriologically a total of

1 Medico-Military Review, September 15, 1921.

2 Michigan State Medical Society Journal, October, 1921.

3 Journal of the American Medical Association, July 1, 1922.

4 Michigan State Medical Society Journal, October, 1921.

6 Journal of the American Medical Association, October 15, 1921.

DIET 329

174 cans of spinach. These wen- selected from various shipments
believed to be connected with botulism outbreaks and also from a
number of other lots which were suspected of being imperfectly pro-
cessed. Of the entire number, 1*2 were normal, and 82 were either
"swollen" or "springy." The term "flat," "swollen" or "springy"
are used to designate the condition of the ends of the can. Normally,
a <an should be "Hat" (slightly concave), owing to a decreased pressure
within the can. The "springy" or "swelled" condition is caused by
an increase in pressure resulting from gas production within the can.
A "springy" can may result also from improper exhausting.

The contents of (i of the 82 abnormal containers were found to be
toxic when fed to guinea-pigs. One of these 6 cans presented a peculiar
condition in that, while animals were regularly killed by feeding small
amounts of the spinach juice, cultures of Bacillus botulinus could not
be obtained.

They found that Bacillus botulinus, Type A, is able to multiply and
to produce its characteristic toxin in canned spinach, although the
development of the organism in this food product was found to be
somewhat irregular.

The important practical information is that of the 6 toxic cans all
were "hard swells," and when opened the odor was distinctly offensive.
The destruction of foodstuffs deemed to be abnormal, either by appear-
ance of the containers or by the odor, should prevent the greater num-
ber of the outbreaks of botulism. From the public health aspect of
the problem, the last point is of special importance.

The thermal death point of Bacillus botulinus spores has been studied
by Weiss.1 The juices of thirty-six varieties of canned food on the
American market furnished the material. He found that the thermal
death-point varies with the hydrogen-ion concentration of the par-
ticular food and also on the consistency of the food, the more fluid
products requiring a shorter period of exposure at a given temperature
than the less fluid ones. The thermal death-point is also influenced
by the presence and concentration of syrup. The heavier the syrup,
the longer the period of exposure required at any one temperature.

Treatment. At present this is unsatisfactory. As pointed out in an
editorial article prompt recognition is important, both in order that
the offending food may be recognized and, when necessary, official
measures of control instituted, and, also in order that botulism anti-
toxin may be given a fair trial. Animal experimentation is somewhat
encouraging, but so far the antitoxin has not shown much benefit in
human cases. It is possible that, as in the original use of diphtheria
antitoxin, the serum is not administered early enough.

Most patients die within four or five days. So far as at present
know7n, the only hope lies in early recognition and the prompt adminis-
tration of the antitoxin.

Bear2 used the antitoxin in several of his cases with varying results.
Wells3 used antitoxin in a single case. He states that definite improve-

1 Journal of Infectious Diseases, October, 1921.

2 Loc. cit. 3 Loc. <it.

330 LANDIS: THERAPEUTIC REFERENDUM

ment in swallowing, in speech, and in general appearance followed the
administration of serum from the third day and at times temporary
relief of the sense of constriction in the throat and of occasional diffi-
culty in breathing was mentioned by the patient about an hour after
the serum injection.

Tup: Caloric Intake. Prior to the food shortage caused by the
World War the measurement of food by computing the calories was
confined to a relatively few. The laity knew nothing of the subject
and the great majority of practising physicians were equally ignorant.
The subject became simplified and practically applicable by interpret-
ing the calories in terms of common household measures. This plan
has been effectively used by Joslin in his Manual for Diabetics and by
Emerson in his Nutrition Classes. Although the method is to be
regarded as a rough measurement it is certainly preferable to the
entire ignorance which formerly prevailed. It at least enables one to
form some idea of how much the patient is getting.

An excellent editorial article1 points out that, as the result of food
restrictions during the war, the caloric intake in the warring countries
fell from 3000 per capita to 1800, to 1000, and in some instances to 800.
As a result, there were some w7ho questioned whether the figure 3000
was not too high and that man would be better off on much less food.
This opinion was formed by the report that diabetes and certain gastro-
intestinal disorders diminished as a result of a restricted food intake.
Later, it became evident that an inevitable result was undernutrition
and the attendant ills.

The article quoted points out that when freedom of choice exists
the intake of the "average" man, no matter where he lives, approx-
imates 2700 calories. The customary food habits of the world repre-
sent an optimum which we must not juggle. The experiences of the
war taught clearly that departure from these standards leads to under-
nutrition and its consequences, from which neither enhanced digestion
nor mastication nor any panacea can furnish protection.

Nutrition Classes. One of the good results of the increased
interest in food values has been to focus attention on the nutritive
needs— the caloric requirements— of children. It is now clearly known
that during adolescence the needs of children of both sexes may exceed
by nearly 1000 calories a day for each person the requirements of the
adult man or woman of moderate activity.

The problem of the undernourished child has been dealt with in
previous issues of Progressive Medicine. It may not be amiss,
however, to recall the various factors which lead to these undernourished
states. These have been summarized by Easton2 in a report of the Child
Welfare Society of Washington, I). C: (1) Late hours. Many
parents considered 9 o'clock as an early hour for bed, and not a few
children went to bed at 11 and 11.30 p.m. (2) Overfatigue. This
resulted from failure to observe periods of rest after overindulgence
in play, and in some cases from lack of proper amount of sleep. (3)

1 Journal of the American Medical Association, December 17, 1021.

2 Ibid., February 4, 1922.

DIET 33]

Insufficient outdoor air by day and night, Some children insisted upon
playing indoors. In the case of families living in apartment houses,
the time for the outing of children was limited because of the house-
hold demands made on the mother. Moreover, the shortage of ade-
quate housing facilities necessitated the use of bedrooms by too large
a number of persons. In a few instances, the window- were not kept
open enough during the night. (4) Two meals a day. These were
the reward of "Late to bed and late to rise." (5) Irregular meals.
The children eating at irregular hours usually found the family table
deserted and grew accustomed not to eat at the table and preferred
eating from the hand. (6) Improper diet. Toffee, tea, sausage and
sauerkraut were samples of the many unsuitable foods which were
given to children under six years of age. Candy between meals seemed
also to be the rule. (7) Diet of low caloric value. This was deter-
mined by calculating the calories of the child's dietary, which was
submitted by the mother.

Obesity and Diabetes. It will be recalled that about a year ago
Joslin called attention to the close relation that existed between obesity
and diabetes, the former only too often carrying with it the penalty of
becoming diabetic. It is interesting that at the time Joslin's article
appeared the Phipps Institute had just completed a survey of the
policemen and firemen of Philadelphia. In this study there were found
25 cases of unsuspected diabetes, and in every case the affected indi-
vidual was obese and sedentary in habit. The lesson to be learned
from these observations is that people who incline to obesity should
regulate their diet and indulge in sufficient exercise to keep the weight
within safe limits.

As many of these so-called "prediabetes" do not show sugar in the
urine under normal conditions, studies are now being made to deter-
mine methods to anticipate the diabetes. Beeler and Fitz1 report on
the glucose tolerance of a group of stout persons exhibiting sugar-free
urines on routine examination. The majority of the patients observed
showed no fasting hyperglycemia and had a nearly normal blood-
sugar curve after the ingestion of 100 gm. of glucose. A few of the
obese, however, showed a curve of glycemia resembling that of mild
diabetes.

Reference has been made to the effect of famine in Europe on the
incidence of diabetes and obesity. While these seem to have dimin-
ished, tuberculosis has certainly been increased as the result of under-
nutrition. Another phase of the diet has been the allegation that the
change in diet has increased the incidence to gastric cancer. This,
according to Janowitz,2 is not true. A careful study made by him
shows no evident alteration in either the number or the location of
cancers of the digestive tract as observed in Berlin during the war,
when compared with a similar group of population before the war.

1 Archives of Internal Medicine, December, 1921.

2 Zeitschrift f. Krebsforsch., 1921, 18, 34.

332 LANDIS: THERAPEUTIC REFERENDUM

Pellagra. Goldberger,1 who has long championed the dietetic
hypothesis of pellagra, has recently reviewed the subject. He con-
cludes that diet controls the course and development of the disease,
and that the relationship then disclosed probably depends primarily
on a specific quality of the amino-acid make-up of the protein supply.

Rickets. A tremendous amount of attention has been devoted to
this disease within the past few years under the heading "heliotherapy."
Reference has been made to the effect of sunlight as a preventative and
curative agent.

McCollum, Simmonds, Shipley and Park2 believe that rickets is
dependent on a diet low in phosphorus and the fat-soluble A vitamin.
Sweet3 expresses the belief that the hypothesis that rickets is due to
a deficiency of fat-soluble A vitamin in the diet has not been proved.
He thinks it is primarily due to a diet deficient in fresh animal food,
probably suitable protein, or to a disturbed digestive condition which
prevents the assimilation of the same. Confinement of young animals
with its attendant evils of lack of sunshine, exercise and cleanliness
are important factors in increasing the severity of the disease.

Vitamins. As usually happens with the introduction of a new thera-
peutic remedy, there follows a period in which the most extravagant
claims are made. At present vitamins occupy a prominent place in
the literature, and, as a result of this, they are being heraled as a panacea
for all sorts of ailments. In an editorial comment4 it is stated that:
"The medical profession is unquestionably facing a problem in con-
nection with the current widespread public propaganda for the thera-
peutic use of yeasts and so-called vitamin preparations. Every person
who reads— whether it be the monthly or weekly magazines, the daily
newspapers, or even the billboards — is likely to find gratuitous reminders
that he is confronted with menaces to health which not only ought to
be averted but can readily be remedied, when present, by the simple
expedient of a patent medicine or proprietary product.

"No one will deny the great contribution which the discovery of
the vitamins has made to physiology and medical progress." It is to
be borne in mind, however, that the source of these substances is to be
found in the garden rather than on the druggists' shelves."

Furthermore, it is well, at present, to keep in mind that relatively
little is known about the vitamins. The British Medical Research
Council in commenting upon this subject says: "The present situa-
tion is a curious one, upon which posterity will probably look back
with great interest. We still have almost no knowledge of the nature
of these elusive food substances or of their mode of action, but we have
gained empirical knowledge already of the greatest practical value
for the prevention of scurvy and of other grave diseases and for the
promotion of health and beauty in the population."

Common sense is much needed at present when vitamins are under

1 Journal of the American Medical Association, June 3, 1922.

2 Journal of Biological Chemistry, August, 1921.

3 British Medical Journal, December 24, 1921.

4 Journal of the American Medical Association, April 15, 1922.

DIET 333

discussion. This attitude is well taken in an editorial comment:1 "A
normal adult," it says, "living on an ordinary diet containing a reason-
able proportion of fresh vegetables is, therefore, certain of obtaining
a plentiful supply of vitamins." Holt,2 in an article on the practical
application of the results of vitamin studies voices the same opinion
in regard to the dietary of children. He states that if the daily diet
contains in reasonable amounts unskimmed milk, cereals, potato,
green vegetables and fruit, one need not fear a vitamin deficiency.
While these articles are especially rich in vitamins, nearly all of our
common foods contain them. "Of all the mass of evidence which
has accumulated relative to these substances, this fact is the point of
greatest importance. It is, however, very unfortunately, the one
point which those commercially inclined are unwilling to recognize."

The commercial aspect of the problem has been studied by McCollum
and Simmonds.3 They state that no evidence whatsoever has been
brought forward to show that an excessive amount of one or another of
the vitamins is of value in the nutrition of either the sick or the well,
but there is today a great wave of enthusiasm on the part of the public
for information concerning them. There prevails in the minds of most
people, they continue, a child-like confidence that these substances must
have a medicinal value. As a result, all sorts of " vitamin preparations"
are being placed on the market, and enthusiastic claims made for their
curative properties. It was for this reason that McCollum and Sim-
monds made a study of a number of these commercial preparations.
They conclude that the claims are extravagant and misleading, and that
the drug store is not the place to secure vitamins.

Emmett4 has contributed an excellent review of vitamins. He
points out that it was some thirty-five or forty years ago that the
etiology of beriberi— an endemic nerve disease which was very preva-
lent in the Orient— was found by the Japanese to be associated with a
faulty diet. Eijkman was able to produce this disease experimentally
in fowl by feeding them on milled rice. Later, Fraser and Stanton
extracted a substance from the rice millings which prevented and
cured the disease— polyneuritis— in pigeons. In 1911, Funk succeeded
in concentrating this substance still further. Since this material
seemed so important to life, Funk called it vitamin.

This vitamin related to and was specific for beriberi. Therefore,
it was designated as the antiberiberi or antineuritic vitamin. Later,
as other vitamins were discovered, it became known as the water-
soluble B type.

In 1913, McCollum and Osborne and Mendel, working independently,
showed that there was another factor that related to growth and body
conditions. This was found to be present and soluble in certain fats
and oils. This is now known as the fat-soluble A type. Besides
these two types there is a third, which Drummond has designated as

1 British Medical Journal, February 11, 1922.

2 Journal of the American Medical Association, July 8, 1922.

3 Ibid., June 24, 1922.

4 Theraputic Gazette, November, December, 1921; January, 1922.

334 LANDIS: THERAPEUTIC REFERENDUM

water-soluble C. This vitamin appears to be specific for scurvy.
Table I, taken from Emmett's article, shows at a glance the distribu-
tion of the vitamins.

TABLE I.

Vitamins appreciably Vitamins practically

present in absent in

Fat-soluble Type.

Cod-liver oil + + + + Yeast

Butter-fat + + + Vegetable oils

Cream . ++ Seeds + ?

Egg fat + + Lard + ?

Green leaves + + Nuts —

Water-soluble B (Anlineuritic )Types.

Yeast + + + Cod-liver oil

Germs of seeds + + + Vegetable oils -

Rice millings + + + Lard -

Natural grains + + Butter-fat

Nuts + + Milled products, as rice flour

Some vegetables + + etc. —

Orange juice .-..++ Cooked foods + ?

Skimmed milk . . . +

Water-soluble C Type.

Lime and lemon juice + + + Yeast —

Orange juice + + + Cod-liver oil

Tomato + + + Nuts

Some fresh vegetables + + Grains and seeds -

Sprouted seeds + + Canned foods -f ?

Fresh unpasteurized Cured meats —

milk + Cooked foods + ?

Table II (also from Emmett) shows the effect of cooking on the
vitamin content of certain foods.

TABLE II.— COMPARATIVE ANTISCORBUTIC (WATER-SOLUBLE c)
VALUE OF EQUIVALENT WEIGHT OF SUBSTANCES.

Fresh lemon or orange juice (raw) 100

" cabbage leaves or juice (raw) 100

" " " cooked 100° C. for 20 min 30

" 70°-80° C. for 70 min 10

" Swede or turnip (raw) 60

" tomatoes (raw) 60

" green beans (raw) 30

Potato, cooked 100° C. for 30 min 7.5

Fresh carrot juice (raw) 7.5

" beet-root juice (raw), less than 7.5

" beet juice (raw) 7.5

Dry beans, peas, etc. (raw) 7.5

Fresh cow's milk (raw) 1 to 1.5

Germinated beans, peas, etc. (raw) 30

Emmett states that there is some evidence to show that there may
be more than three vitamins. Some observers believe that there are
two or three additional ones.

In commenting on the methods needed to determine the presence
or absence of any one of the vitamins in a food or food product, Emmett
states that the tests necessary require more than ordinary precautions.

DIET 335

The origin of vitamin .1 has been investigated by Coward and Drum-
mond.1 Seeds in genera] arc deficient in vitamin A. On the other
hand, this is known to be relatively abundant in the green, actively
assimilating parts of plant tissues. According to Coward and Druni-
mond, there is no increase in vitamin A when seeds are germinated.
Nor is there any gain when the latter are etiolated in the dark. Etio-
lated seedlings and pale-colored leaves deficient in chlorophyl apparently
do not synthetize vitamin A; on the other hand, green leaves form it in
large amounts. Lower plants, such as marine algse, containing chloro-
phyl, synthetize this dietary factor; others, such as weeds, which are
differently adopted for photosynthesis, are not so active in this respect;
while mushrooms, devoid of pigments, which are concerned with carbon
assimilation, are almost completely deficient. The vitamin A in green
leaves does not appear to be associated with proteins. It may be
extracted in the fat removed by solvents, and appears in that fraction
of the fat which is resistant to saponification.

The chief source of vitamin B in our food is the seeds of cereals and
other plants, but the factor is removed from cereal seeds in the process
of milling. Sugar, sago and other farinaceous products are lacking
in B factor, meat and fish are poor and eggs in comparison are rich.
Vegetables and milk contain small amounts. The quantity in these
foodstuffs is scarcely sufficient to balance the large carbohydrate con-
sumption of white flour in our diet, unless eggs, fruit and vegetables
are eaten in great quantities. The products richest in vitamin B are
the germ of cereals and yeast.2

In a study of the distribution of vitamin B, Damon3 found that
commercial beef extract and peptones are devoid of this substance.

Osborne and Mendel,4 in a series of experiments, find that asparagus,
celery, dandelion, lettuce and parsley all contain noteworthy amounts
of vitamin B. Asparagus proved to be unexpectedly rich in the B
type. Yeast, which contains vitamin B, has been exploited a great
deal and is much used by the laity. Daniels5 has employed yeast in
the feeding of infants. She found that the most noticeable general
effects of the yeast additions, especially with young babies, was the
change in the number and character of the stools, a formed "safe"
stool, often becoming diarrheal. In many instances not only was the
character of the stool changed, but the number per day was greatly
increased, even when comparatively small amounts of yeast were
used. These frequent diarrheal stools wrere, in a number of cases,
followed by sudden losses of weight, and the results were sometimes so
disastrous that it was necessary to institute corrective measures at
once. She, therefore, concludes that yeast should not be used as a
means of increasing the antineuritic content of infant's food.

The antiscorbutic properties of dehydrated fruits have been studied

1 Biochemical Journal, 1921, 15, 530.

2 Therapeutic Gazette, 1922, p. 264.

3 Journal of the American Medical Association, July 8, 1922.

4 Ibid., April 15, 1922.

5 American Journal of the Diseases of Children, January, 1922.

336 LANDIS: THERAPEUTIC REFERENDUM

by Eckman.1 He found that the only one of the dried fruits tested,
which contains sufficient antiscorbutic vitamins to maintain the life
of a guinea-pig when fed in not too excessive qualities, is peaches. Of
this fruit, it appears that 4 gm. a day, although insufficient to prevent
scurvy, delays it for three or four months. Apricots and apples have
some value, but pears, prunes, loganberries and cherries seemed to
have very little. In a similar study, Givens, McClugage and Van
Home2 report that the raw apple and the raw banana are antiscorbutic
agents. If, however, either of these fruits is subjected to any con-
siderable temperature treatment, such as ordinarily employed in preser-
vation by desiccation or canning, the amount of antiscorbutic vitamin
in the original raw material is markedly reduced.

The effect of heat and oxidation on the antiscorbutic vitamin has
been studied by Dutcher, Harshaw and Hall.3 They found it is not
destroyed by heating at pasteurization temperature (63° C.) for thirty
minutes in closed vessels or by boiling (100° C.) for thirty minutes
under reflux condensers. Hydrogen peroxide possesses some destruc-
tive action when added to orange juice at room temperature and the
destructive action is increased when the orange-juice-hydrogen-per-
oxide mixture is heated at 63° and 100° C.

Chick and Dalyell4 report a satisfactory result in stimulating growth
and progress of 9 very backward children, varying in age from twelve
to thirty-one months, by the use of antiscorbutic juices and of fats
containing the fat-soluble vitamin A. Eight of the 9 children treated
gave a history of previous attacks of definite scurvy.

Water-drinkinCx and Hypertension. It is probably true that
the majority of clinicians are of the opinion that a large fluid intake
(water) is to be avoided in cases of arterial hypertension. It is interest-
ing to note that Oer and Innes5 have studied the influence of increased
water ingestion on the blood-pressure of some apparently normal
subjects, and also in pathologic cases in which there was high arterial
tension. They found that the addition of from two to three quarts of
water to the normal daily consumption is followed by a distinct fall
in both systolic and diastolic pressure. The fall is not accompanied
by an increase of either the rate or the force of the heart-beat, and the
increased pressure is maintained for some time after the extra water
has been excreted. Oer and Innes incline to the view that the chief
factor in producing the fall of pressure is the elimination of pressor
substances that cause arterial constriction and thereby produce an
unnecessary augmented arterial tension.

It is important that this observation be confirmed.

Digitalis. Hatcher and Weiss6 believe that nausea and vomiting
are of fundamental importance for the protection of various organs

1 Journal of the American Medical Association, March 4, 1922.

2 American Journal of the Diseases of Children, March, 1922.

3 Journal of Biological Chemistry, August, 1921.

4 British Medical Journal, December 24, 1921.

6 British Journal of Experimental Pathology, 1922, 3, 61.
6 Archives of Internal Medicine, May, 1922.

DIGITALIS 337

and tissues against digitalis poisoning (using that term in its broadest
sense), and different organs have developed this protective mechanism
independently <>t* the irritant action which these substances exert on
the gastric mucous membrane. They point out that it is especially

interesting in this connection to observe that rodents, which are incap-
able of vomiting,, have developed several different, and apparently
independent, methods of protecting themselves against the toxic action
of digitalis bodies on the heart, and also against the injurious action
of various other vegetable poisons. Hatcher and Weiss conclude, from
their experiments, that digitalis bodies cause reflex nausea and vomiting
through direct action on the heart. The apparent impulses pass from
the heart to the vomiting center in the medulla, by way of the sym-
pathetic mainly; in part, by way of the vagus, probably.

Another of the toxic effects of digitalis, namely, cerebral and neuro-
muscular manifestations, is commented on by Macht and Bloom.1
They recall that Withering, in his original communication, pointed
out that "The foxglove, when given in very large and quickly repeated
doses, occasions sickness, vomiting, purging, dizziness, distorted vision
effects (appearing green or yellow), increased secretions of urine with
frequent motions to part with it, slow pulse (even as slow as 35 to a
minute), cold sweats, convulsions, syncope and death." In 1874
Duroziez called attention to the cerebral symptoms, reporting 20
cases in which delirium or hullucinations, with or without death, accom-
panied the administration of digitalis, and wThich he believed were
caused thereby. It is, of course, recognized that cerebral symptoms
in the course of heart disease are not at all uncommon, but it is not
sufficiently known that hallucinations, delirium and other mental
affections occur at the height of digitalis therapy.

Macht and Bloom, in an experimental study of the effects of digitalis
on rats, obtained data which would seem to confirm the clinical observa-
tions of Duroziez and others. They believe these symptoms are more
common than is generally supposed. Several physicians, whom they
have consulted, have had cases in which there seemed to be no doubt
but that digitalis was capable of causing these cerebral disturbances.

Christian2 believes that the dangers or toxic effects of digitalis
are more serious as met with in the text-books than in actual practice.
In his opinion, the real dangers of digitalis therapy are these: (1)
Using a poor digitalis preparation; (2) consciously, or unconsciously,
prescribing too little of a patent digitalis preparation; and (3) not
knowing when digitalis should be started and stopped. Christian
states that he has yet to see the patient in whom too much digitalis
had been given prior to his seeing him. The large majority have had
too little digitalis; a small percentage have had enough; none have had
too much; and some have had too little from the point of view of dosage
when actually they should have had none. In his opinion digitalis
poisoning, while possible, is one of the nineties of medicine.

Digitalis is needed when the patient has the symptoms and signs

1 Archives of Internal Medicine, November, 1921.

2 Boston Medical and Surgical Journal, July 13, 1922.

338 LANDIS: THERAPEUTIC REFERENDUM

of failing compensation. The symptoms and signs of decompensation
are breathlessness, cough, cyanosis, edema, pain, weakness, nausea,
vomiting, enlargement of the liver, decreased urinary output, rapid
pulse.

The indications for stopping the drug are improvement in these
symptoms and signs, or the occurrence of the toxic effect of digitalis.
The toxic effects are nausea, vomiting, rarely diarrhea, and certain
arrhythmias, as bigeminal pulse and heart-block.

It is to be borne in mind that the digitalis which the patient purchases
only too often has but slight potency. In addition, a serious error is
to regard a drop as the equivalent of a minim and to prescribe 15 drops
of the tincture, thinking to give 15 minims; the patient taking 15 drops
often gets but 5 minims, rarely more than 7 minims— both very small
doses. This error accounts for much unconscious prescribing of too
small a dose; the rest comes from a preparation of low potency.

There should be definite evidences of cardiac insufficiency before
digitalis is given. An increased heart-rate alone is never the result
of cardiac insufficiency and never an indication of digitalis. Paroxys-
mal tachycardia does not respond to digitalis, and digitalis does not
affect simple tachycardia. No murmur of whatever sort, nor enlarge-
ment of the heart, in itself is an indication for digitalis.

Christian states that the digitalis may be given in a single massive
dose, or in a modified massive dose method, or in regularly repeated
small doses. Any of these methods is effective. The chief difference
lies in the length of time needed to produce a result. In his opinion
there is no real preference for the average cardiac case. In a few very
severe cases the modified massive dose method is preferable, and
occasionally the single massive dose may be life-saving.

In Christian's opinion digitalis therapy is very simple. Enough of
a potent leaf, prepared in any way, should be given by any accepted
method of dosage and the result is most satisfactory in almost every
case.

The use of digitalis in 2 cases of cardiac arrhythmia following diph-
theria is reported by Bile and Schwensen.1 In addition to the
arrhythmia, both children had enlargement of the liver due to the
cardiac weakness and arrhythmia. In both cases digitalis was used
with the prompt disappearance of the arrhythmia, the tracing became
normal with the exception of a few extrasystoles. In 1 case the enlarge-
ment of the liver disappeared simultaneously with the relief of the
arrhythmia; in the second case the liver became much enlarged, with
the onset of the irregular partial heart-block. Bile and Schwensen
believe that their experience with these 2 cases makes it probable that
in the treatment of these otherwise fatal cases with digitalis in full
doses there may be a chance of saving the damaged myocardium from
the great exertion caused by the irregularity.

The question of the potency of digitalis preparations is a most import-
ant one. From time to time analyses are made showing that many

1 Journal of Infectious Diseases, March, 1922.

EMETINE 339

samples arc inefficient. Bliss1 reports obtaining fifteen samples of
infusion of digitalis, selected at random from retail pharmacies. They
showed an average activity of but 42.26 per cent of the theoretical
activity calculated from the amount of standardized drug supposedly
used in the manufacture of the infusion. Bliss states that five of the
fifteen samples prepared by a method that is disapproved of by the
medical and pharmaceutical professions (simple dilution of the fluid
extract), showed an average activity of 62.6 per cent, or 16.34 per cent
stronger than the average of the fifteen samples, and 24.5 per cent
stronger than the ten samples supposedly prepared by the U. S. P.
(IX method) The last-mentioned samples showed an average activity
of but 2S.1 per cent.

Eggleston and VYykoff2 summarize their conclusions on the absorption
of digitalis as follows:

1. The absorption of high-grade specimens of tincture of digitalis
from the digestive tract of man is almost invariably sufficiently uniform
to permit the establishment of a satisfactory working average total
dose in terms of the cat unit of activity per pound of the patient's
body weight.

2. Specimens of tincture of average biologic activity are occasionally
encountered which are therapeutically unsatisfactory on account of
poor absorption from the alimentary canal.

3. Tincture of digitalis shows definite evidences of action on the
heart in from two to four hours after oral administration to man.

4. Poorly absorbed tinctures may require more than five hours for
the development of demonstrable cardiac action.

5. A method of preparing and standardizing a purified tincture of
digitalis is described.

6. The purified tincture is shown to be absorbed from the human
digestive tract more rapidly and more nearly uniformly than are differ-
ent specimens of official tincture of average biologic activity.

7. Considerable variation in the capacity of different individuals to
absorb digitalis is shown to exist.

8. Evidence is offered to show that digitalis causes nausea or vomit-
ing in man by reflexes arising in the heart as a result of its intoxication.

9. An average total dose of the purified tincture for oral administra-
tion to man is established on the basis of its cat unit of activity and
the patient's body weight.

Christian,3 in commenting on the standardization of digitalis in
animals, states that it is helpful, but by no means essential.

Emetine. In the treatment of bilharziasis, Cawston4 claimed the
best results for emetine hydrochloride, given intramuscularly daily for
three days and then three times a week for three weeks. The initial
dose for an adult is 0.5 gr. and for a child 0.33| gr. A dose of 1 gr. is
a sufficiently large one to work up to in a child of twelve years. The

1 Journal of Laboratory of Clinical Medicine, January, 1922.

2 Archives of Internal Medicine, August, 1922.

3 Loc. cit.

4 Lancet, November 19, 1921.

340 LANDIS: THERAPEUTIC REFERENDUM

maximum regular dose for an adult is 2 gr.; larger doses appear to
cause toxic effects but to cure more rapidly. Vomiting may occur if
the injection is given shortly after a meal. There is a cumulative
action of emetine almost as marked as the required tolerance for anti-
mony, therefore the dose should be diminished or given less frequently
toward the close of the treatment. The object is to keep the patient
under the influence of the emetine without producing undesirable
toxic effects. A slight return of albuminuria indicates toxemia and
is an indication, just as in the case with antimony, that the dose should
be diminished or given at less frequent intervals. As a rule, the treat-
ment should be extended over a period of twenty-five days.

In another communication, Cawston1 reports an experience with
more than 300 injections of emetine hydrochloride. He concludes that
when the drug is given skilfully and regulated properly this method
of treating bilharzia disease is free from undesirable toxic effects, and
is permanently successful in eradicating the infection. He feels that,
in view of the difficulty in determining slight cardiac depressions due
to the large doses required by adults, the emetine treatment should
be confined to children and young persons, and careful attention paid
to the pulse-rate throughout. Provided undue exertion is avoided,
there is no reason for the patient's being confined to bed. Moderate
exercise is useful in determining when the highest dose the patient
can comfortably tolerate is reached.

Bonnet2 reports a single case of bilharziasis treated with emetine.
No living parasites or living ova could be found after the fifteenth
injection. The treatment was continued for fifty-three days, the
doses being given at intervals. Bonnet states that, aside from the
characteristic asthenia under this treatment and tendency to vertigo
toward the last, there were no appreciable untoward effects.

In the treatment of dysentery with emetine, Jepps3 reminds us that
emetine is highly toxic to man and other animals, and as it is neces-
sary for the removal of the amoeba to employ the drug in doses of such
size that there is in many cases a slight, and in some a severe, toxic
effect on the patient. It is because of this that there still seems to be a
strong feeling in the minds of some against the use of emetine under
any circumstances, in spite of the many series of results now published,
in none of which is there any record of more than temporary ill-effects,
the drug always being administered under careful medical supervision
and stopped when considered advisable.

The following routine is recommended by Jeppe in giving the emetine-
bismuth-iodide mixture: The patients were not kept in bed, but
allowed to be up and about on a very light diet. The diet consisted
of milk, bovril, fish without vegetables, bread and butter and two
eggs daily. After the patients were put to bed they received 10 minims
of chlorodyne, and half an hour later the dose of emetine-bismuth-iodide
mixture in water. They were allowed to have hot tea afterward if

1 Journal of Tropical Medicine and Hygiene, May 1, 1922.

2 Journal d'Urologie, July, 1921.

3 Journal of the Royal Army Medical Corps, June, 1921.

END0CR1NES 341

they wished. In tins way the vomiting and general discomfort were
reduced to a minimum. Vomiting may occur after the first few doses,
but is not serious and does not necessitate stopping the treatment.
Most of the patients had more or less diarrhea during the treatment.

There were never any cardiac symptoms. In the whole series of
treatments (75 eases) the course had to he stopped only on account
of severe diarrhea, and in 1 case because of a high temperature which
could not be attributed to any other cause. The amount of vomiting
is dependent, to a large extent, on ward conditions; a nervous or trouble-
some patient may easily upset others, and tactful supervision may
do a great deal toward preventing it.

Jepps summarizes his conclusions as follows:

1. Salol-coated pills of emetine-bismuth-iodide proved unsatis-
factory; 45.1 per cent (at least) of 26 cases relapsed after a twelve-day
course of 36 gr.

2. An emulsion of emetine-bismuth-iodide in liquid paraffine gave
much better results. Of 63 cases given a twelve days' course of 36
grains, only 12.7 per cent relapsed. After retreatment of a few of
these relapsed cases with a double course, 11.1 per cent were still uncured.

3. Further analysis of these figures shows that of 57 cases showing no
intestinal symptoms, or only slight symptoms, 3.5 per cent had not
been cured; while of 6 acute and subacute cases 5, or 83.3 per cent,
had remained positive.

4. Injections of emetine hydrochloride were found very useful in
cases where the emetine-bismuth-iodide treatment could not be toler-
ated. Three out of 5 cases were cured by a course of twelve daily
injections of 1 gr. each.

5. The treatment proved beneficial to the patient's general condi-
tion, and there were no permanent ill-effects.

Soca1 reports a fatal case of polyneuritis following eighteen days of
treatment, with a total of 1.05 gm. of emetine for dysentery. He
states that he has observed a number of cases exhibiting toxic symp-
toms and that these were regularly observed when the dose of 8 eg.
was repeated for several days in succession.

A complete and permanent cure of an amebic liver abscess with
emetine alone is reported by Tolzi.2

Endocrines. Hoskins3 sounds a timely warning in regard to the
indiscriminate use of the gland products and to emphasize the fact
that the problem is a very complicated one. There is still much to
be learned. As he states: "Little is to be expected from nonchalant
attempts to solve these problems by superficial observations. Nor
can a thoughtful clinician take seriously the claim that overenthusiastic
use of gland products is to the best interest of the patient. The argu-
ments adduced are precisely the stock arguments of the cultists and
nostrum venders. Ultimately, practical organotherapy will have to be
reduced to a statistical basis. This will require the accumulation of

1 Bulletins de la Societe Medicale de Hopitaux, May 12, 1922.

2 Policlinico, May 15, 1922.

3 Journal of the American Medical Association, July 8, 1922.

342 LANDIS: THERAPEUTIC REFERENDUM

a much greater fund of well-established observations, both positive
and negative. There is need for many more careful studies of indi-
vidual eases as well as extensive series of cases. Almost any endo-
crine case presents a research problem worthy of exacting study."

Hoskins advocates the establishment of a hospital or clinic especially
equipped to make an intensive study of endocrinology.

Ether. The effects of ether on respiration has been studied by E. P.
Smith.1 Using concentrations of 1, 3.65 and 7.3 per cent, he noted
that the first effect is to cause a depression in the respiratory rate.
This is followed by a rapid rise above normal, which, in turn, is suc-
ceeded by a fall. With all the concentrations the respiration is ulti-
mately reduced to approximately the same level; the stronger the ether,
the less time required to produce this result. Even when the respira-
tion has been reduced below normal, recovery is possible on removal
of the ether, and appears to be complete, if sufficient time is allowed.
If, however, the rate has been too far depressed no recovery is possible.

Ether is recommended by Vacearezza and Inda2 in the treatment
of whooping-cough. The amount injected varies from 0.5 to 2 cc,
according to age. The drug is injected intragluteally every day for
three days and then on alternate days. Three injections are often all
that is needed. Sometimes the heart-rate is accelerated for about an
hour. According to these authors, the course of the disease is short-
ened, and, in the favorable cases the cough loses its spasmodic character.

Exercise and Rest. The employment of these two agents in the
treatment of pulmonary or, in fact, any form of tuberculosis is not
as well understood by many practitioners as it should be. And this
is in spite of the fact that the literature on the subject is enormous.
The prevailing mistake is to neglect the rest and prescribe or permit
of exercise at a time when the latter is usually harmful and in many
cases actually disastrous. On the other hand, there can be no doubt
but that rest is carried to an extreme in some cases and, having first
been useful, later becomes harmful.

The only safe-working rule is to institute treatment in all cases
with a period of rest in bed. Generally speaking, this should be a month.
During this period one then has the opportunity of gauging the degree
of toxicity present, particularly the amount and the character of the
fever. If fever is absent exercise can be undertaken safely in a very
short time; if fever has been present, but quickly subsides, with rest
in bed, exercise can be advised after a brief period. On the other
hand, persistent fever, marked loss of weight, nervous exhaustion as
manifested by malaise and often mental depression does not permit
of exercise or even of the patient's sitting up. Rest must be persisted
in. The only exception to this rule is in the case of the hopelessly
advanced disease in which nothing is to be hoped for no matter what
is done. The main problem with this type of case is to make him
comfortable.

1 Journal of General Physiology, November, 1921.

2 Semana Medica, October 6, 1921; Abstract, Journal of the American Medical
Association.

EXERCISE AND REST 343

One thing is certain, no man ever acquires the ability t<> determine
at the time of the initial visit how long rest must be carried out, or
to estimate with any degree of accuracy how active the disease is.
At the end of a month's rest in bed a fairly accurate opinion may be
hazarded.

Much the same opinions have been expressed in an editorial article.1
For some years I have alluded to the fact that the so-called rest-cure
treatment for nervous and mental disturbances, as introduced by
Weir Mitchell, was in reality the foundation of our modern method
of treating pulmonary tuberculosis. Mitchell, in his original presen-
tation of the subject, in 1870, included in his case histories many cases
of obvious tuberculosis, and others in which it was clear that a latent
tuberculous process was at the bottom of the nervous exhaustion or
neurasthenia. The fundamental principles of the rest treatment are
rest, generous feeding, isolation from business and social distraction,
and, in certain cases, the use of electricity and massage. Omitting
the last-mentioned agents, you have the modern method of handling
tuberculosis. The editorial referred to regrets the fact that the Weir
Mitchell method has been, as a rule, limited to cases of nervous
exhaustion. As a matter of fact, the method is largely applied as I
have stated without any appreciation of the source.

I have already alluded to the fact that in not a few instances, patients
are kept on rest too long. In such cases they are apt to take on too
much weight, and, furthermore, weight that is not beneficial. They
are fat and flabby and unable to stand anything. What is far worse,
they only too often become profoundly neurasthenic, are afraid to
move, become self-centered and selfish and a burden to themselves
and everyone around them. The second state of many of these people
is worse than the first. They have had the tuberculous lesion arrested,
but are prevented from resuming a normal life, because of their physi-
cal and nervous condition. It often takes considerable effort and skill
to overcome these handicaps.

The effects of exercise in heart disease have been studied by Peabody
and Sturgis.2 They made a study of dyspnea on 1 1 ambulatory patients
with heart disease, and a similar group of normal subjects while stand-
ing at rest. They found that the oxygen consumption and heart-rate
were slightly greater in the former. Also, under the same conditions,
the minute volume of the respiration was much greater in the patients
with heart disease and the breathing was more rapid and more shallow.
The slight amount of exercise involved in walking up sixty steps pro-
duced the same relative changes in oxygen consumption, pulmonary
ventilation and heart-rate in both groups, but it caused more subjec-
tive dyspnea in the patients with heart disease. Exercise which was
severe enough to cause a corresponding amount of dyspnea in normal
subjects caused the same type of changes in oxygen consumption, pul-
monary ventilation and heart-rate, but they were greater in degree.

Shortness of breath in heart cases was most noticeable immediately

1 Therapeutic Gazette, 1922, p. 32.

2 Archives of Internal Medicine, March, 1922.

344 LANDIS: THERAPEUTIC REFERENDUM

after exercise was stopped, and at this time the pulmonary ventilation
was largest. It is suggested that the two factors which account for
the greater dyspnea in the cardiac patients are the inadequate circu-
lation, which results in a delayed elimination of carbon dioxide, and the
tendency to shallow breathing, which necessitates a relatively large
pulmonary ventilation.

Starling1 states that in the management of failure of compensation the
most important factor is rest, which not only diminishes the demands
on the heart from the arterial side, but by removing the main cause
for the return of blood to the heart enormously decreases the inflow into
this organ; and it is inflow which in the healthy heart determines output.

Starling believes that another factor of great importance in enabling
the heart muscle to recover its physiologic condition is the circulation
through the coronary vessels. The most important factor in deter-
mining the amount of blood flowing through the coronary arteries, and
therefore the oxygen supply to the heart muscle, is the arterial pressure,
so that as the resistance to the heart-beat increases there is a corre-
sponding increase in the flow of the blood through the heart muscle.

Starling states that the enormous range of adjustment in the coro-
nary circulation characteristic of the healthy heart enables us to form
some idea of the evil results which must follow impairment of the
power of adjustment, such as may occur in consequence of disease of
the coronary arteries themselves. We may see how rapidly such a
failure of adjustment may act on the heart muscle by repeating Cohn-
heim's experiment of ligature of one main branch of the coronaries.
This is almost invariably followed within a period varying from a
couple of minutes to half an hour, by the fibrillation of the ventricles
and death of the animal, and a similar result may occur in man as a
result of any unequal derangement in the powers of adjustment possessed
by different parts of the coronary system.

Starling is inclined to ascribe the beneficial effects of graduated exer-
cise in heart disease very largely to improvement of the coronary
circulation brought about by the temporary rise of arterial pressure
accompanying the exercises.

Heliotherapy. Although it has been known for some years now
that the effect of the sun's rays, and even of artificial lights, has a most
potent effect on various diseased conditions, the medical profession as
a whole has been backward in availing itself of this powerful therapeutic
agent. Recently the subject has been forcibly brought to the atten-
tion through the indisputable demonstration by various investigators,
both here and abroad, that sunlight, and notably the ultra-violet
rays, have a marked curative effect on certain forms of rickets, as well
as a prophylactic influence when this disease is apt to develop.

Considerable work has been done in the attempt to obtain informa-
tion on the possible chemical reactions associated with these various
light effects, particularly on the ultra-violet rays. So far, it would
seem that these rays may act on proteins, so as to render them less

1 Lancet, December 10, 1921.

HELIOTHERAPY 345

soluble. The harmful effects of light <»n bacteria may depend on
such changes in the protein constituents of their living protoplasm.
For instance, solutions of albumin in quartz vessels behave like solu-
tions of the more readily precipitated protein globulin after being

subjected to ultra-violet rays. Ordinary glass is a harrier to thee
potent rays, a fact which should always be home in mind in contrasting
the possible effects of sunshine indoors and outdoors.1

DeGroer2 states that exposure to the sun's rays produces a typical
hemoelastic crisis, hut this is transient, and is followed by a leukocy-
tosis. When only a well-tanned region is exposed to the rays the
hemolysis does not occur, the pigmentation evidently protecting against
it. From this he concludes that the regions exposed should he sys-
tematically arranged so as to have always some non-tanned region
available.

DeGroer likens the effects of the rays to parenteral protein therapy.
He states that the changes apt to be induced throughout the organism
by the exposures to the chemical rays can be demonstrated by the
Schick test. He inoculated the back with diphtheria toxin, four and
two hours before the test, during the test and again two and four hours
afterward. Instead of completing the test with antitoxin, as in Schick's
original method, he exposed the abdomen to the chemical rays, and
gives an illustration which clearly shows the difference in the reaction
when the system is, or has been, recently under the influence of chemical
rays. Every exposure to them acts like a poison on living matter.
Besides the local inflammatory reaction, the absorption of products
from the damaged cells induces a general reaction. The mechanism of
protein poisoning from an extensive burn, according to De Groer, differs
only in degree from that induced by the action of sunlight or mercury
vapor light. As previously pointed out, the great interest in helio-
therapy at present is its curative and prophylactic powders in the man-
agement of rickets.

Hess3 points out that one must bear in mind constantly that rickets
is preeminently a seasonal disorder, and that it is characterized by a
striking seasonal variation. Clinicians as well as pathologists are in
complete agreement as to its marked incidence in the winter and spring,
and comparative rarity in the summer. In his own experience three-
quarters of the cases develop during the first half of the calendar year,
and but one-quarter during the second half, and that almost all of the
latter are observed late in November and in December. This seasonal
factor is climatic, not dietetic, and due almost entirely to lack of sunlight.

Another noteworthy factor is the pigmentation of the skin. It has
been shown experimentally that if two groups of rats, one composed
of white rats, and the other of black rats, are given the minimal pro-
tective dose of light it will be found that although diet and rate of
growth have been the same, the black rats will develop rickets, whereas
the white rats will show7 no rachitic lesion. This is borne out in infants.

1 Journal of the American Medical Association, July 1, 1922, p. 42.

2 Annales de Medecine, January, 1922.

3 Journal of the American Medical Association, April 22, 1922.

346 LANDIS: THERAPEUTIC REFERENDUM

Negro infants require a greater degree of the effective light rays than
do white infants. That they possess no racial predisposition to rickets
is evidenced by their freedom from this disorder in their native homes
in West India. Hess also believes that the darkness of the skin is a
predisposing factor also, in the susceptibility of the Southern Italian,
the Syrian and other southern races. He does not imply from these
statements that susceptibility is merely a question of degree of pig-
mentation of the skin, but rather that light is an important etiologic
factor in determining the efficacy of light.

In an article on the care of infantile rickets by sunlight, Hess and
Gutman1 give the following directions:

The infants were placed in the direct sunlight for from one-half hour
to several hours, the period varying according to the sun's intensity,
the clemency of the weather and the sensitiveness of the baby. It is
necessary that the sunlight be direct, and not transmitted through
clothing or through the window glass; otherwise it loses the greater
part of its curative potency, as the result of filtering out the effective
rays. As has been stated in a previous communication, such treat-
ment cannot be carried out in a routine manner, but must be varied
according to the condition of the babies, some of whom are far more
sensitive to sunlight than others. At all times, care was taken that
the infants were warm. It was found quite sufficient to expose the
arms and legs, although it is preferable, when the temperature permits,
to expose the trunk as well.

Previous to treatment, the majority of infants showed the clinical
symptoms of mild rickets, characterized by beading of the ribs, and
the characteristic changes in the epiphyses are seen by roentgen-ray
examination. All the children were receiving the customary milk
mixtures and orange juice, the older ones getting cereal in addition.
Reliance was not placed entirely on the roentgen-ray examination of the
bones, as it has been our experience that infants may manifest the
classical signs of rickets, accompanied by a low inorganic phosphate
of the blood, and, nevertheless, show normal bony contours at the
wrists and other joints.

In every instance in which heliotherapy was employed the rachitic
signs diminished, as was demonstrated clinically and by roentgen ray,
and the general condition improved.

In addition, Hess and Gutman found that, as the condition improved,
the inorganic phosphate of the blood was gradually restored to the
normal level. This result is similar to that which has been attained
by means of cod-liver oil, which must be considered a specific for this
disorder.

Powers, Park, Shipley, McCollum and Simmonds2 report the results
of an experiment on the effects of sunlight in the prevention of rickets
in rats. Their results are summarized as follows:

1. The object of the experiment was to determine whether or not
sunlight prevents the development of rickets in the rat.

1 Journal of the American Medical Association, January 7, 1922.

2 Ibid., January 21, 1922.

KELI0THERAP1 347

2. A diet was employed which at room light regularly gives rise t<>
a disease in its essential features identical with rickets as seen in human
beings. The diet was high in calcium, low in phosphorus and was
insufficiently supplied with fat-soluble A. In other respects it was well
constituted.

.'!. Eighteen rats were placed on the diet. Twelve were exposed to
sunlight for a total of two hundred and forty-two hours over a period
of sixty-two days. Six were kept under conditions of ordinary room
light as control animals.

4. The control rats, killed with ether at the end of sixty days, all
showed rickets.

5. The rats exposed to sunlight, killed coincidently, remained with-
out exception entirely free from rickets. The absence of the lesions of
rickets was confirmed by histologic examination.

(>. The beneficial effects of the sun's rays w^ere not limited to the
skeleton, since the condition of the animals underwent a general improve-
ment under the influence of the treatment with sunlight. The effect
of the sunlight on the skeleton was a manifestation of its favorable
effect only on a single tissue.

7. The exposure to the sun's rays, however, did not entirely com-
pensate for the defects in the diet. The animals remained undersized;
the bones, though completely calcified, remained thin. Though the
sunlight did not alter the defects in the diet, it permitted the animals
to thrive to a limited extent in the presence of them.

8. It is necessary to conclude, therefore, that the sunlight in some
way raises the efficiency of the body cells. It enables the organism
to put into operation regulatory mechanisms which otherwise would
have been inoperative or ineffectual.

9. The effects of sunlight and of cod-liver oil on the growth and
calcification of the skeleton and on the animal as a whole seem to be
similar, if not identical.

Lovett,1 in commenting on the various factors which are of benefit
in the treatment of rickets closes as follows: "Recent investigations
have shown that there is a real basis for the empirical teachings of the
past that out-of-doors, phosphorus and cod-liver oil were of use in the
treatment of rickets. They leave us somewhat in the dark, however,
as to how to prevent it. It w^ould seem, sunlight being beneficial
only when it strikes directly on the body, as if it was not sufficient to
keep babies in airy, sunny houses, but that their naked bodies must
be wholly or partly exposed to the sun's rays. It will be rather diffi-
cult to persuade the average mother to do this regularly in the winter,
as a preventive, although she will probably do it gladly as a curative
measure. These investigations show us little or nothing as to how
a baby should be fed to prevent the appearance of rickets. It still
seems safe, however, to follow the old teachings that human milk is
the best food for babies, and, next to it, some modification of cow's
milk. It may be that the time will come when all babies will be given

1 Boston Medical and Surgical Journal, April 13, 1922.

348 LANDIS: THERAPEUTIC REFERENDUM

cod-liner oil as a preventive. It seems evident, at any rate, that cod-
liver oil will cure rickets. As it is the easiest and simplest method, it
would seem to be the one of election. Phosphorus also seems to have
a definite curative action. It is, however, a dangerous drug and the
limits of its dosage narrow. It is, therefore, inferior to cod-liver oil
for ordinary use."

One of the first diseases in which heliotherapy was applied was
tuberculosis, especially the so-called surgical type. Turnbull1 has
reported the use of sunlight in the treatment of children having or sus-
pected of having tuberculosis. The majority of the children under
Turnbull's care were of the so-called pretuberculous type. About 10
per cent had tubercle bacilli in the sputum and an additional 10 per
cent had toxic symptoms or surgical complications necessitating special
care.

In applying the treatment, a special class was made of the sick
children and those with surgical complications. These were placed
on blankets on the lawn under the care of a nurse. Their exposure to
the sun was regulated according to the principles laid down by R oilier,
the lower extremities being exposed for fifteen minutes the first day,
the time of exposure and the area exposed being increased from day
to day. After exposure of the entire naked body was secured, an
arbitrary maximum of three hours' exposure daily was decided upon,
this being divided into two exposures of not over one and a half hours
each. The nurse was held strictly responsible for avoiding sunburn.
It was found that different types of skin reacted very differently in this
respect and that great care was necessary during early exposure.
- Turnbull states that, contrary to what they feared, there were no
bad results from the sunlight, even in the positive sputum cases. In
only 2 cases was there a tendency to headache and rise of temperature
after exposure. In both cases this was controlled by protecting the
head and eyes by a straw hat.

The good results were shown by disappearance of cough, increased
appetite, increased muscular development even in cases taking no
exercise, greater regularity of temperature and decrease of pain in
surgical cases.

In handling the large pretuberculous group a modified method was
adopted. The boys were dressed in the lightest cotton bathing suits
that could be procured. For the girls, a loose-fitting, one-piece, bifur-
cated garment was made, reaching from the angles of the scapula- to
the middle of the thighs, and held up by narrow shoulder straps. Shoes,
stockings and underclothing were discarded. These suits were worn
constantly at school and at play.

Turnbull feels that, while it is inadvisable to be too positive as to
the relation between cause and effect, it is the opinion of those who
have been caring for the children in his institution for some years,
that they have never done so well or improved so rapidly as they have
during the past two years. The two most notable effects were the

1 Therapeutic Gazette, May, 1922.

HELIOTHERAPY 349

filling out of wasted arm and shoulder muscles and the disappearance
of glandular enlargements. In addition, the children have been remark-
ably free from ordinary colds and nasal infections, in spite of the fact
that they have worn their scanty uniforms on the playground during
rain as well as in the sunshine. He also applied heliotherapy in 25
cases of active pulmonary tuberculosis. He thinks the results so far
obtained are sufficiently encouraging to continue the method in this
type of case.

Turnbull points out that since sun exposure is necessary for the
proper growth of plants and animals, it is a logical therapeutic agent in
disease characterized by low vitality. In pulmonary tuberculosis of
children, graduated sun exposure appears to be free from danger and
to give excellent results. In the so-called pretuberculous cases the
results are better than those from any other line of treatment. In
adults the results may be considered encouraging. Turnbull's experi-
ence indicates that the dangers of properly graduated sun exposure
in pulmonary tuberculosis have probably been overdrawn by some
writers.

A combination of sea bathing and heliotherapy is advocated by
Gauvain1 in the treatment of surgical tuberculosis. He first allows
ambulant patients to paddle for increasing periods; later they are
sprayed with cold sea water over increasing areas of the body and,
finally, full immersion is permitted.

Recumbent patients are first sprayed and later immersed, as their
condition permits, for carefully graduated periods. A brisk reaction
is sought, and this is hastened by taking each patient from the sea
and placing him within a protected enclosure where he is wiped down
before the radiant heat of an open coke brazier. The patient's feet
are placed in warm water and he is given a hot drink. This is followed
by a sun bath.

Gauvain states that the stimulating effect of this procedure is remark-
able. The immersion in the sea water is followed by deeper respira-
tions of great amplitude, which effectually expand the lungs and expel
waste products. The circulation is also favorably affected. The first
chilling effect causes a constriction of the superficial capillaries, followed,
when reaction occurs, by their cilatation. All parts of the body are
flushed by an increased volume of blood and lymph, the blood supply
to diseased tissues likewise increasing. Excretion from the lungs, skin
and kidneys is increased.

Gauvain believes that sea bathing followed by a brisk rub and a
graduated sun bath produces a sense of exhilaration and well-being,
and physical improvement much greater than the sun treatment alone.
This is especially true of lupus.

Kern2 favors the use of actinotherapy in conditions calling for helio-
therapy. He states that the ultra-violet rays are antiseptic, bacteri-
cidal, markedly analgesic, a sedative to the nerves and that they assist
in promoting general metabolism. In tuberculous patients it is prefer-

1 British Journal of Tuberculosis, July, 1922.

2 Ohio State Medical Journal, April, 1922.

350 LANDIS: THERAPEUTIC REFERENDUM

able to the natural sunlight on account of its applicability at all places
and in all climates. It is especially so in cases that must be treated in
their homes.

The actinic rays are especially valuable in the treatment of neuralgia
and neuritis. Kern states that in these conditions immediate relief
is afforded in many cases. In chronic cases the actinic rays must be
continued for a prolonged period in order to obtain results.

In a review of the subject, Ahlswede1 points out that the lack of
sufficient sunlight in northern Europe led to the search for adequate
substitutes. These were found chiefly in the shape of the Finsen lamp,
and the mercury-vapor lamp. According to Axel Hensen and Johan-
sen, the Finsen light most nearly approaches sunlight in its effect.
It contains the same proportions of short-waved rays and long-waved
penetrating rays provided the filament in the arc light is exactly com-
posed. The mercury-vapor lamps, on the other hand, differ from the
light of the sun inasmuch as they show a line spectrum compared with
the continuous uninterrupted spectrum of the sunlight.

The biologic and therapeutic effect of rays on the skin depends on
their wave length. The shorter the wave length, the shorter the effect
on the surface of the skin. The superficial layer of the epidermis
absorbs the short-waved rays; at the site of absorption a strong super-
ficial influence is seen. The long-waved rays, on the other hand, are
more penetrating and go deeper into the subcutis and body. It is,
therefore, necessary to cut off the mercury-vapor spectrum at a certain
wave length to get as near as possible to the spectrum of the sun.

It is advisable to use mercury-vapor lamps at one yard distance,
but in cases in which a stimulating effect is desired (wounds) the short-
waved ray may prove useful.

Ahlswede states that the effect of light on an unprotected skin shows
the following visible degrees of intensity: Erythema due to heat;
inflammation due to light; and pigmentation. The erythema is seen
immediately after exposure of skin. It shows a hyperemia which
rarely lasts more than an hour and then disappears. Mercury-vapor
lamps do not cause this reaction as heat rays are not contained in
their spectrum.

The inflammation of the skin by light is generally seen in from five
to ten hours after exposure. The degree of the inflammation depends
on the length of exposure and the intensity of the light.

As to the pigmentation, this is generally seen two to five days after
the exposure to light. It is a defensive action of the system against
the light; the erythema gradually turns darker, almost brown and the
skin begins to peel off. The skin gets accustomed to the light and
its sensibility decreases to a degree which renders an inflammation of
the skin, even after long exposure to intense rays, impossible. This,
however, can be said only wTith regard to the Finsen light and sunlight.
Mercury-vapor rays always cause erythema; the skin cannot become
immune to their influence.

1 Urologic and Cutaneous Review, September, 1921.

HYDROCHLORIC ACID 351

It is to be borne in mind that light has its effect in the body and not
alone on its surface. It has been shown that the Finsen light caused
an increase of hemoglobin and the red blood corpuscles. Hertel showed
that, under the influence of light, hemoglobin passes its oxygen on to
the tissues more quickly. The bactericidal power of light is well
known. That internal organs may be influenced is indicated by the
fact that the ultra-violet rays cause changes in the spleen in mice,
followed by an increase of giant cells.

Amstad1 points out conditions which are especially benefited by
heliotherapy. He emphasizes the beneficial effect of the treatment
on the entire system as evidenced from the improvement of the blood
picture. In 17 cases of lymphogranuloma systematic heliotherapy
arrested the disease for a year or two, and the general condition was
immeasurably improved. These patients had all been sent to him as
cases of advanced glandular tuberculosis. He believes that in an
earlier stage heliotherapy offers prospects of a complete cure.

Rickets is cured by sunlight, and Amstad believes it should be applied
more generally in order to prevent the appearance of the disease.

The treatment of wounds by exposure to sunlight is too much neglected
in Amstad's opinion. He begins after three days to expose the wounds
to the sun, holding them open with retractors; even large defects heal
over in ten or twelve weeks.

Amstad deplores the dependence on drugs and the neglect of such
natural resources as sunlight, particularly in dealing with wounds and
the giving of sun baths to infants in order to prevent rickets.

Hexamethylenamine. In a study of drug therapy in pyelitis, Helm-
holz2 states that in acute cases the alkalies are useful, but there is no
evidence of any direct specific effect, except possibly a diuretic action.
From a study of the literature, Helmholz has gained the impression,
especially in the pyelitis of infancy, that hexamethylenamine is not of
much value. His own conclusion is that while the drug has a very
definite bactericidal action in the bladder, it has not been demonstrated
that this is also true of the pelvis of the kidney.

Hydrochloric Acid. In the treatment of pernicious anemia, Bil3
advocates the use of hydrochloric acid in order to restore normal con-
ditions in the stomach and upper part of the small intestine. He
introduces once a day, on an empty stomach, by means of a thin sound
(6 mm. in diameter), a hydrochloric acid solution of about the same
strength and volume as the acid secreted after a meal. This procedure.
he believes, brings about an acid reaction in the upper part of the
small intestine, which tends to hinder, or to diminish, pathologic decom-
position of the intestinal contents by ridding it of bacteria.

McClure and Ellis4 are of the belief that dilute hydrochloric acid is
not, in acid-sensitive cases at least, the harmless tonic the text-books
would lead us to accept. In their opinion when the acid is being

1 Schweizerische med. Wochenschrift, January 26, 1922.

2 Journal of the American Medical Association, July 22, 1922.

3 Lancet, April 1, 1922.

4 Ibid., August 6, 1921.

352 LANDI8: THERAPEUTIC REFERENDUM

administered the blood-pressure should be estimated from time to time
and the urine occasionally tested for its acid and ammonia relations.

If an early renal insufficiency is suspected the "rest urine" should
be compared with the "alkaline tide urine" in respect to their relative
acidity.

McClure and Ellis state that acid largely regulates the amount
and character of the urine excreted by its action on the renal tissue.
This is largely controlled by the increasing acidity of the blood
(acidemia), tending to raise the blood-pressure; otherwise the kidneys
would not be able to maintain the necessary balance between acid
and alkali. When kidney impairment takes place, owing to the break-
down of the chemical balance, general acid sensitiveness occurs, and
this is accompanied by a rise in blood-pressure. If, however, the
structure of the renal cells is not injured, this is not maintained unless
the acidemia continues. On the other hand, if the structure of the cells
is injured the rise of the blood-pressure is more or less permanent until
other forms of compensation are established. If this state of affairs
arises the administration of acid and acid-feeding are contraindicated.
In doubtful cases the blood-pressure should be watched to avoid over-
dosing with the acid. The latter is indicated by the "alkali-tide
urine," approaching the "rest urine" in character.

McClure and Ellis assume that the reason why, during the adminis-
tration of acid, a rise in blood-pressure is not easily reversible, that is,
followed by a more or less similar fall, while this subsequent fall in
blood-pressure is not easily reversible, is because acidosis may be trans-
ferred to the tissues, the acidemia thus being changed into a histo-
acidosis, and this causes a fall in the blood-pressure. If histo-acidosis
occurs it is not easy to raise the blood-pressure again, because of the
difficulty either of raising the acid content of the blood above that of
the tissues, or of reducing the acidity of the tissues below that of the
blood, the fluid pressure thus persisting toward the tissues, while the
balance is against the blood.

Iodides. The use of iodides in the treatment of the mycotic infections
is a recognized procedure. In the treatment of oidiomycosis (blasto-
mycosis), Farnell1 recommends the intravenous use of hypertonic
iodides. He used sodium iodide exclusively in at least 400 injections.
The preparation is made in from 8 to 13 per cent (10 per cent is the usual
strength) solutions in distilled water, to the amount of 100 cc. This
is then boiled and cooled, and given by gravity intravenously. The
solution is freshly made for each treatment. Farnell states that in
this way a distinctly hypertonic solution of high concentration is
produced. He did not note in any case irritation of the digestive
tract; skin eruptions occurred in 1 case and coryza in another. He
believes that iodine injected with the blood stream in hypertonic form
has a tendency to reduce the idiosyncrasy toward iodism. In addi-
tion to benefiting the mycotic infections, iodides given intravenously
in concentrated form appear to help materially the action of arsphena-
mine on the diseased tissues and cells.

1 Archives of Neurology and Psychiatry, June, 1922.

IRON 353

Iodine has been so generally approved as an efficient skin antiseptic
in emergency operations and in the first-aid treatment of wounds, thai
it comes as a surprise to learn from Colcord1 that the method is not
without its faults. He states that the iodine destroys a layer of tissue
over the wound surface without selection, and that this must be removed
before healing can begin. Furthermore, it furnishes a favorable culture
medium for bacteria. He asserts that the teaching that every indi-
vidual wound is potentially infected is misleading and lias done harm.
With proper cleaning and debridement, almost every such wound will
heal without clinical infection, the body cells and fluids taking care of
the usual bacteria remaining. Mechanical debridement with forceps
and knife or scissors should be done, and this followed with the applica-
tion of sodium hypochlorite solution.

Colcord is opposed to the teaching that employees should be per-
mitted to treat wounds when well-equipped dressing stations and
trained nurses and surgeons are available. He thinks the dictum that
iodine should always be applied at once before sending the man to the
doctor is a pernicious one. Such a course is permissible only when
several hours must elapse before the man can be seen.

Iodine, he states, has been shown to be far inferior to Dakin's solu^-
tion, Ochsner's fluid or dichloramine-T. Silver nitrate, bichloride of
mercury, iodine and carbolic acid coagulate albumen and favor infec-
tion. They also, by this very infection, block up the lymph channels
and so prevent the outpouring of lymph into a wound, so necessary
for its germicidal powers.

What is necessary in industrial surgery is clean technic, through
cleansing, proper suturing, drainage, splintage and rest.

Iron. The value of iron in the treatment of anemia continues to be
the subject of controversy, despite the fact that most physicians and
the laity in general are of the belief that iron is of service in dealing
with impoverished blood states. Experience has shown that, as a
rule, unnecessarily large doses are too often given. The one exception
to this seems to be in the chlorotic type of anemia, in which large
doses do seem to be essential, although the reason does not seem clear.

The failure of iron to favorably affect anemia has been the subject
of experimental studies. Whipple and Robscheit2 produced second-
ary anemia in dogs by bleeding, and then carried out a very exhaustive
study as to the influence of various preparations of iron in the regenera-
tion of the blood. These investigators claim that their experiments
give no support to the time-honored custom of administering iron and
certain other drugs in conditions of simple anemia, and that the burden
of the proof rests with those who claim that any given drug is potent
under such conditions.

They do not deny that patients who are taking iron and arsenic
improve but this they attribute to dietetic conditions rather than the
drugs.

1 International Journal of Surgery, April, 1922.

2 Archives of Internal Medicine, 1921.

354 LANDIS: THERAPEUTIC REFERENDUM

Musser1 studied animals which had been repeatedly deprived of
small amounts of blood over various intervals of time, and thus ren-
dered anemic. The anemia that these animals showed represented the
type of anemia which occurs after recurring loss of small amounts of
blood and the type which the physician is called in most frequently
to treat.

Musser administered to these animals iron in the form of equal
parts of ferrous sulphate and sodium bicarbonate, in quantities equiva-
lent to 2 gm. (30 gr.) of iron a day for man. His results coincided
with those of Whipple and Robscheit in that the dose of inorganic
iron failed to produce any constant alteration in the course of the
experimental hemorrhagic anemias.

Hare,2 in an editorial comment on the work of Whipple and Robscheit,
points out that pharmacologic investigations on animals are of the
greatest possible value in that they increase our general knowledge and
often correct error. On the other hand, he protests against the labora-
tory investigator lightly brushing away the experience of thousands
of clinicians after making a few experiments upon animals, not that
the results obtained are valueless or lacking in interest, but because
the two sides of the evidence have not been adequately considered.

Again, Hare states, that "What the clinician needs is not alone
investigations which seem to disprove the value of things in which he
has confidence, but investigations which go far enough to not only
correct him, but to explain matters which are obscure, and, in addition,
at least offer a substitute for the remedy which has been claimed to be
without value."

Kaolin. China clay, bolus alba, or kaolin, is aluminum silicate,
a salt insoluble in water, with crystals of 1 micron in length in a fine
state of division. Walker3 states that it was in use in early Roman
times and was also used by the natives of the Orinoco. It has also
been employed in diphtheria in Germany as a powder insufflated on
the fauces and tonsils, and also a mixture internally. It has also
been used in a variety of gastro-intestinal disorders, namely, ptomaine
poisoning, dysenteries, summer diarrhea of children and toxic condi-
tions. Walker reports on its use in the treatment of Asiatic cholera.
He refers to Kulme's work in the Balkan war (1913). By the use of
kaolin, Kulme claims the mortality was reduced from 60 to 3 per cent.
His method of preparation was as follows: A suspension was made of
equal amounts of kaolin and water, the kaolin being stirred into the
cold water. Half-pint doses of this suspension were taken half-hourly
for the first twelve hours; the second twelve hours several glasses were
taken, according to the patient's condition. Vomiting soon ceased, the
pulse improved and the patient slept. The general effect of the salt
seems to point to the absorption of toxins.

Braafladt, in an epidemic in China, in 1919, gives the following
results of various treatments:

1 Archives of Internal Medicine, November, 1921.

2 Therapeutic Gazette, November, 1921.

3 Lancet, August 6, 1921.

LUMINAL 355

1. Hypertonic saline treatment, after the method of Rogers, gave a
mortality of 22 per cent. Convalescents discharged on the eighth day.

2. Kaolin and hypertonic saline treatment gave a mortality of 29 per
cent. Convalescents discharged on the sixth day.

3. Kaolin treatments alone; mortality, in :!"> cases, 1 patient (this
patient died of gangrene of the uterus after miscarriage). ( 'onvalescent
patients discharged after four days.

All these patients had true cholera vibrios, being isolated during their
stay in the hospital. Walker states that the advantages of the kaolin
treatment are: (1) Simplicity of method; (2) absence of relapse; (3)
cessation of loss of fluid; (4) great improvement in the condition of
the patient from the absorption of toxins, the patient becoming rapidly
free from a general "toxic condition;" (5) early return of the passage
of the urine; (6) early and rapid convalescence.

In a series of 75 cases, from a village two hours' journey from the
hospital, Walker had no fatalities, and this result was obtained in spite
of the fact that many of the patients arrived at the hospital in a condi-
tion of extreme collapse. The mortality of untreated cases at this
village was stated by the village headman to be exceedingly high, though
he was unable to obtain exact figures owing to the absence in China
of any registration of deaths.

The kaolin aids, by absorbing toxins and coating the entire body,
enmeshing the vibrios.

Luminal This drug came prominently to the front a few years ago
as a nervous sedative, particularly in the treatment of epilepsy. During
the past year a number of articles have appeared on its use.

Luminal is phenylethyl-malonylurea, or a derivative of veronal, in
which one of the ethyl groups is replaced by a phenyl radical. Luminal
sodium is a soluble derivative of luminal and may be given in hot milk
or water, in doses of 1 to 2 grs. once a day, usually at bed time.

Continental observers consider 3 or 4 grs. daily safe, provided the
patient is under proper supervision.

Fox1 employed sodium luminal in 16 cases of ordinary epilepsy in
children or adolescents. There was a marked reduction in the fit
incidence in every case. This uniformity of reaction to the drug places
it, according to Fox, in a category apart from other antiepileptic
remedies.

Luminal sodium seems to give the best results in cases liable to
major epileptic attacks. Cases which suffer from momentary losses
of consciousness, or from periodic short attacks of altered consciousness
with automatism, are notoriously inaccessible to drug treatment.
Even in this type of case, Fox obtained some good effects. Fox
warns that sodium luminal is not to be looked upon as a curative
agent, but simply as one that, at its best, only arrests, or limits, the
frequency of the convulsive attacks.

Austin2 has employed luminal in a group of 49 epileptics for fifteen
months. The daily dose was from 1 to 5 grs. In common with others

1 Lancet, September 10, 1921.

' Ohio State Medical Journal, October 1, 1921,

356 LANDIS: THERAPEUTIC REFERENDUM

who have employed the drug, Austin does not consider it a curative
agent, but simply one that will ameliorate the seizures. So far, the
drug has given better results than any other remedy employed in the
treatment of the essential epilepsies. Those patients who received the
luminal are in as good physical and mental condition as at the beginning
of the treatment and many are much improved. No untoward results
were observed.

In a series of 50 cases of epilepsy Small1 reports 80 per cent responding
well to the luminal.

Stanton2 administered the drug to 100 epileptics. In practically all
cases there was a diminution in either the number or severity of the
seizures, and in many instances the seizures disappeared. Stanton
believes that luminal, accompanied by bromides in the early stages
of the treatment, gives better results than luminal alone. If a rapid
effect is desired, Stanton states that it is possible to use the luminal
sodium preparation in a 20 per cent solution subcutaneously.

Austin3 also recommends the drug subcutaneously in doses of from
1.05 to 5 grs. in cases of status epilepticus and mania; in the same
states 5 to 10 grs. may be given per rectum.

In some cases the character of major seizures has been replaced by
an atypical one, in which there is no tonic convulsion, but a furor of
considerable violence, of irregular body movements, with total or partial
loss of consciousness. In other cases major seizures are controlled or
replaced with minor ones in which loss of consciousness is sometimes
incomplete.

Rawnsley4 reports the case of a child subject to convulsive seizures.
The attacks increased in number and severity until as many as three
a day occurred. The child was given luminal, 1 gr. at bedtime, and
a weekly purge. In the course of one month there was only an occa-
sional mild attack of a transitory character, with giddiness and slight
momentary spasms of the arms, but no loss of consciousness. A month
later she had occasional attacks of giddiness only.

Galla,5 in an analysis of his results with luminal, states that 36 out
of a total of 125 cases were either not improved or deteriorated under
the use of the drug, while the remainder did better under luminal
than under bromide. The cases most beneficially affected by luminal
were those with fits occurring at frequent intervals, and the cases
least affected were those whose fits occurred in bouts at considerable
intervals of time. The doses employed by Galla rarely exceeded 6 grs.
a day of the sodium salt. (In regard to dosage and untoward effects,

see below.)

In commenting on the difference of results in different types of
cases, Galla states that it would appear probable that a class of epilep-
tics exists who are more refractory to bromide treatment than others;

1 Virginia Medical Monthly, October, 1921.

2 Michigan State Medical Society Journal, January, 1922.

3 Loc. cit.

4 Journal of the Royal Army Medical Corps, March, 1922.

5 British Medical Journal, August 27, 1921.

LUMINAL 357

such a class would obviously show the greatest number of fits when
treated by bromides, hut at the same time the patients are not less
susceptible to luminal than their fellows, and, consequently, it is with
these eases that the drug shows its most marked effect.

Yoje1 states that luminal reduces undue excitability of the cortex
and subcortical strata of the brain without unpleasant constitutional
or mental effects, and is, therefore, a superior remedy to the bromides
in the treatment of epilepsy. Furthermore, luminal is helpful in over-
coming any kind of mental or nervous excitement, and seems to be
superior to other remedies in combating the drug, tobacco and alcohol
habit.

In luminal sleep the nerve cells rest and recuperate, and poisons are
eliminated. Any kind of delirium or maniacal attacks, therefore, are
overcome much quicker while the patient is in this slumber, with few
exceptions.

Jackson and Fell,2 in a report of their experiences with luminal,
'(include as follows:

1. That luminal in doses of 1 and l\ grs. daily reduces the convulsion
curve.

2. After a period of time the drug loses its effect and there is a secon-
dary elevation of the convulsion curve.

3. Increased doses reduce again the convulsion curve, but there is
a secondary elevation on increased doses, and a distinct elevation on
the complete withdrawal of the drug. This is no doubt due to increased
tolerance to drug and the lack of a curative effect.

4. In 2 of the cases, after withdrawal of the drug, seizures were severe;
patients developed status epilepticus and died.

5. Luminal reduces the convulsion curve, but will not completely
eliminate the convulsions.

(i. Prolonged use of luminal is not free from danger, and withdrawal
of the drug should be carried out with greatest care and precaution.

7. The degree of postepileptic confusion and furor was lessened in
2 cases.

8. Luminal offers temporary relief, but the value of its treatment
in the custodial epileptic is doubtful, as established tolerance necessi-
tates higher dosage, the continued use and withdrawal of same being
associated with serious phenomena.

Dercum3 takes exception to the last conclusion. He states that in
asylums we have to do with cases of epilepsy so far advanced in their
degeneration that mental symptoms have led to institutional restraint,
and also with other mental diseases in which epileptiform attacks are
merely symptomatic of an underlying mental disease.

In Dercum's opinion no remedy has proved of so much value as lum-
inal in the ordinary so-called essential form of epilepsy, as met with
in general practice. Furthermore, it is apparently harmless and needs
but one dose daily, namely, 1 gr. or 1| grs. at bedtime.

1 Chicago Medical Recorder, February, 1922.

2 Therapeutic Gazette, December, 1921.

3 Ibid.

358 LANDIS: THERAPEUTIC REFERENDUM

The seizures are inhibited for long periods of time and in some cases
altogether, no recurrences being noted. At the same time there is a
marked improvement in the patient's general health. Dercum states
that what the results of the administration of luminal in large doses
would be, especially in persons presenting serious degenerative mental
disease, opens an entirely different problem. In his opinion a sharp
distinction should be made in the application of luminal in these two
groups of cases.

The drug has now been employed sufficiently long to obtain some
information as to its untoward effects. Galla1 states that of the 125
patients treated by him there were 12 who complained of giddiness
and drowsiness. Five of these patients showed a definite disturbance
of the gait, reeling slightly as if under the influence of alcohol. By
diminishing the dose of the luminal, he was able to secure eventual
toleration in all but 4 of the 12 patients who complained so persistently
of the giddiness that the luminal treatment was suspended. Urticarial
rashes appeared in 2 cases at the onset of treatment, but disappeared
when it had been continued for a few days. There was no evidence
of a tendency to habit formation.

Phillips, in reporting a case of luminal (phenobarbital) poisoning,
has collected a number of others from the literature. From these
observations he draws the following conclusions:

1. In view of the severe skin rashes, gastro-intestinal symptoms and
nephritis that may develop as the result of the use of phenobarbital,
this drug should be administered with great care.

2. Since there is little difference between the therapeutic and fatal
dose, phenobarbital should not be prescribed in single doses of more
than l\ grs. (0.1 gm.), and not more than 3 grs. (0.2 gm.) should be
taken in twenty-four hours.

3. A patient under phenobarbital treatment should be instructed
that, on the first appearance of a skin rash or of any untoward symptoms,
he should stop the drug and report to his physician at once.

4. The urine of a patient under phenobarbital treatment should be
examined once or twice a week.

5. Phenobarbital should not be dispensed by druggists except on the
prescription of a physician.

McNerthney2 reports the case of a woman who took a massive dose
of luminal, amounting to 75 grs. According to bystanders, she became
drowsy, with continuous yawning in ten minutes. When seen by
McNerthney, three-quarters of an hour later, she was in a deep, quiet
sleep, the pupils being slightly contracted and sluggish to light. She
was given apomorphine without producing vomiting and her stomach
washed out twice. She remained in a profound sleep for eight hours
and then gradually assumed her usual state of mind. During the time
she was asleep the respiratory and pulse-rate seemed but slightly
changed from normal.

Curiously enough, eight months after taking this massive dose she

1 Loc. cit.

2 Therapeutic Gazette, February, 1922.

MERC 11!) 359

has been free from epileptic seizures, although previously she would
have only an occasional period of from four to six days without one.

Magnesium Sulphate. Two eases of poisoning from the use of mag-
nesium sulphate are reported by Anderson.1 One of the children was
suffering from Uncinariasis, and the other from Ta-nia nana. Both
were given 2 ounces of a saturated solution of magnesium sulphate,
following which each child had four or five large watery stools. The
following morning breakfast was omitted and at 6, 8 and 10 a.m., 1
child was given 8 grs. of the oleoresin of male fern and the other 8 grs.
of thymol. At noon both were given 1| ounces of a saturated solution
of magnesium sulphate. No purging followed this second dose. Ten
hours later both children were profoundly collapsed. They com-
plained of intense abdominal pain, of being hot, were nauseated and
vomited coffee-ground vomitus almost continuously, so that no food
was retained for forty-eight hours. Both children would sink into a
comatose state, the respiration being scarcely perceptible and very
slow and deep. At all times, however, they could be aroused, tell how
they felt and their mentalities were clear. Their extremities were cold
the pulse could hardly be felt at the wrist and the heart sounds were
rapid and weak. There was no jaundice or convulsions.

There was slight general rigidity of the abdomen. For about twenty
hours there was suppression of both urine and feces.

Treatment consisted of high colon irrigations with physiologic sodium
chloride solution and 5 per cent glucose solution given per rectum.
This was followed by improvement. The children were able to retain
coffee, the pulse became stronger, the respiratory rate returned to
normal and the stuporous condition slowly disappeared. Within four
or five days the children had returned to their normal condition.

Mercury. The effect of organic mercury compounds on tubercle
bacilli has been studied by DeWitt.2 She found that the power of
phenol to inhibit the growTth of the tubercle bacillus was greatly increased
by the substitution of a mercury salt in place of one of the hydrogens.
She also found that, while saligenin or phenol carbinol has the same
inhibitory power as phenol, the mercury derivatives of this have a
greatly increased efficiency, varying somewhat with the percentage of
mercury. In the anilin compounds, also, the substitution of a mercury
group great increases the efficiency.

The use of mercury by mouth in the treatment of syphilis was once
the almost universal method. Milian3 points out this method is
again being more generally employed. In order to overcome the
intolerance which sometimes accompanies this method, Milian recom-
mends mixing 0.75 gm. of bismuth subnitrate with 0.01 gm. of calomel
(for one of sixty powders). He states that this combination is an
excellent means of warding off signs of intolerance. The bismuth
seems to prevent diarrhea, anorexia, stomach derangements and even
stomatitis, when mercury is given by mouth. He advises giving the

1 Georgia Medical Association Journal, December, 1921.

2 Journal of Infectious Diseases, April, 1922.

3 Bulletins de la Societe MSdicale des Hopitaux, November 11, 1921.

oGO LANDIS: THERAPEUTIC REFERENDUM

mercury in this way, even if only to supplement other routes. The
bismuth must be continued as long as the mercury is being given.
Milian believes that this combination has a spirocheticidal action of
its own.

In an article on the clean inunction treatment of syphilis wTith mer-
cury, Cole, Gericke and Sollmann1 state that the inunction method is
not employed by many for several reasons: (1) Because it is dirty
and disagreeable; (2) it is apt to lead to discovery; and (3) when the
preparation remains on the skin for any length of time it is apt to set
up a folliculitis. They treated 44 patients in the following way: Four
grams of the official unguentum hydrargyri (U. S. P.) were rubbed in
for thirty minutes. At the end of this time all mercury remaining was
thoroughly removed from the skin by the free use of benzine and cotton.
With these patients a different spot was used each night for at least
six nights, in order to prevent chances of irritation of the skin and thus
forestall the criticism that mercury was being absorbed through the
irritated skin. As a result of this preliminary study, they believe
that in treating syphilis by the inunction method it is probable that the
only mercury absorbed is that part which is rubbed into the hair follicles
and entrances of the sebaceous and sweat glands. Hence, all super-
fluous ointment remaining on the skin may be cleansed off immediately
after the inunction without lessening the mercurial effect.

As a result of this experience with 44 cases, they believe that in the
future mercurial inunctions need not be discarded because of the unplea-
sant consideration in regard to their use, namely, uncleanliness, the fear
of discovery and causing a folliculitis. They, furthermore, recommend
this technic in the treatment of syphilis as a distinct advance in the
therapy of the disease.

The same authors2 have also made a study of the effect of the inhala-
tion of mercury fumes in the treatment of syphilis. Their results
indicate that the administration of mercury compounds by inhalation
has no advantage over oral administration. On the contrary, it has
the serious disadvantage of indefinite dosage, and the consequent
difficulty of steering between inefficiency and danger, and of special
danger of respiratory irritation.

Almkvist3 has reported 26 cases of mercurial tonsillitis. The tonsils
were involved alone in 15 cases; in 9 others it was accompanied with
gingivitis or stomatitis; and in 2 others there was salivation. He
regards the condition as merely the casual localization in the throat
of an ordinary mercurial stomatitis, but it is often mistaken for Vincent's
angina. Fever was present in but 2 of the cases. The angina per-
sisted for from one to twenty-two days after the beginning of treatment.
Both tonsils were involved in 9 instances.

The angina developed as early as after the second injection of mer-
cury in some cases; in others, not until up to forty-eight days after
the last injection.

1 Journal of the American Medical Association, December 24, 1921.

2 Archives of Dermatology and Syphilology, January, 1922.

3 Hygiea, October 16, 1921 ; Abstract, Journal of the American Medical Associal ion.

MERCURY 361

Cases of poisoning with mercury continue to be reported, bul not to

the extent of a few years ago. That they should occur at all is almost
inexplicable in view of the fact, that the accident is so common and,
as a rule, is so freely commented upon in the lay press, owing to the
social prominence of many of the victims. The danger of keeping
mercuric tablets in a household is, or should be, generally appreciated,
so that taking these tablets by mistake for aspirin or similar popular
remedies should be impossible.

In past years there have been reports of systemic poisoning as the
result of the introduction of bichloride tablets or strong mercury solu-
tions into the vagina. All of these cases have been the result of using
the drug without a doctor's advice and, as a rule, for the prevention of
conception.

Sexton1 reports the case of a woman, who used a strong mercury
solution (mercuric chloride) as a vaginal douche. Within an hour
she was seized with violent abdominal pain and vomited. A profuse
and painful diarrhea began about two hours later, with the passage of
much blood-stained fluid.

The urine diminished within five or six hours and by fourteen hours
was completely suppressed.

The patient died on the sixth day. The autopsy revealed a general
peritonitis of moderate degree. In the region of the hepatic flexure of
the colon the intestine, for a distance of fourteen inches, was markedly
inflamed and infiltrated.

The kidneys were uniformly congested, and the substance, on section,
presented a cooked appearance. The pyramids were extremely prom-
inent and the capsules stripped readily. Sexton attributes the sudden
development of symptoms to the fact that the solution probably passed
into the uterus, and thence through the tubes into the peritoneal cavity
where it was rapidly absorbed.

A case of mercury poisoning with recovery is reported by Ellsworth.2
The patient, a woman, took, with suicidal intent, 120 cc of a solution
of bichloride of mercury containing 4 gins, of the salt. The patient
vomited freely shortly after taking the poison, and, when seen shortly
after by a physician, the stomach was washed out with four quarts of
warm water and than half a quart of milk and the whites of two eggs
were poured into the stomach. The latter was vomited almost imme-
diately.

The quantity of urine from the sixteenth day was never less than 1500
cc and increased with the fluid intake. The albumin became less and
none was found after the twentieth day. No casts were found after
the twenty-first day.

In view of the fact that the patient vomited almost at once after
swallowing the solution, it is probable that only a small portion of the
mercury could have remained or been absorbed. Another case of
poisoning with recovery is reported by Funk and Weiss.3

1 Journal of the American Medical Association, May 13, 1922.

2 Pennsylvania Medical Journal, June, 1922.

3 Journal of Laboratory and Clinical Medicine, January, 1922.

362 LANDIS: THERAPEUTIC REFERENDUM

Certain drugs, notably the silver salts, are prone to produce dis-
coloration of the skin. Goeckermann1 has observed 2 patients with
localized pigmentation of the skin, resulting apparently from mercurial
salts in a face cream. In both cases the discoloration on the face and
neck presented the appearance of skin that was not sufficiently washed.
Both patients were advised to wash the discolored parts of the skin with
a 2 per cent aqueous solution of acetic acid twice daily. In 1 case the
discoloration was appreciably lighter at the end of three months. _ It
was then decided to use a 1 per cent aqueous solution of potassium
cyanide, because of its well-known ability to form water-soluble salts
with some of the heavy metals, including mercury. Three months
later the patient stated that the discoloration was constantly growing
lighter but had not yet entirely disappeared. The second case also
responded to the acetic acid solution, but disappeared after six weeks'
treatment.

Goeckermann points out that the pigmentation is apt to persist,
even with proper solvents, as the deposit is actually within the gland
ducts and therefore relatively inaccessible to a solvent.

Another untoward effect of mercury is described by Gougerat and
Plamoutier.2 They describe cases in which a severe dermatitis, edema
of the skin and mucous membranes, and diarrhea with hemorrhage
followed application of mercury to the scalp, or as a mouth wash, or
by subcutaneous injection. In other cases there were severe local
reactions to the injections of mercury. They believe these cases offer
a prospect of successful desensitization whether the disturbances occur
on the first taking of the drug (idiosyncrasy) or the intolerance develop-
ing later (anaphylaxis). Certain recent experiences seem to indicate
that a small preliminary dose may offer protection.

They also report the case of a man who developed an intense des-
quamating eruption on resuming mercurial treatment by mouth after
seven years' suspension. He had never shown any intolerance pre-
viously. The symptoms of the anaphylaxis to mercury developed
after a very small amount of mercury had been taken. Pruritus
appeared on the third day and the eruption on the fifth day. The
tenth day it became intense, but there were none of the usual symptoms
of mercurial poisoning. The eruption could be induced and banished
at will by giving or withdrawing small doses of mercury by mouth.

Methylene Blue. The use of a saturated solution of methylene
blue is advised by Rosenblatt and Stivelman3 in the treatment of tuber-
culous pyopneumothorax. Three cubic centimeters are injected at a
time until sterilization is effected.

Nicotine. This is a very rapidly-acting and fatal poison, being
equaled only by hydrocyanic acid. McNally4 calls attention to the
fact that commercial preparations, containing from 8 to 43 per cent
of the alkaloid, are used in very dilute solutions as insecticides. These

1 Journal of the American Medical Association, August 19, 1922.

2 Bulletin de la SociSte Medicale des Hopitaux, June 2, 1922.

3 American Review of Tuberculosis, December, 1921.

4 Journal of the American Medical Association, July 30, 1921.

NITRITES 363

solutions are occasionally taken accidentally or with suicidal intent.
McNally reports the case of a man who took a liquid containing 42.4
per cent of nicotine, thinking it was whiskey because of the brown
color.

He was admitted to the hospital in an unconscious condition, with
slow, stertorous breathing and gurgling sound in the throat on each
inspiration. The systolic pressure was 110 and the diastolic 74. The
pupils were equal and contracted. There was no evidence of a corrosive
poison.

The treatment consisted of washing out the stomach with water
and tannic acid, and the washing continued until the fluid returned
clear. The patient made an uneventful recovery, regaining conscious-
ness shortly after the stomach had been washed out.

McNally attributes his recovery to the early and copious vomiting
and the efficient washing out of the stomach, as the amount of the
poison he took was enough to have killed several persons.

Nitrites. Ever since the nitrites were introduced by the late Sir
Lauder Brunton, for the relief of pain in angina pectoris, these salts
have been employed quite generally. Many have seen the relief given
by the inhalation of the fumes of amyl nitrite or the hypodermic use
of nitroglycerine, with or without morphine. Attacks also are aborted
apparently by the oral administration of nitroglycerine or sodium
nitrite. Brunton employed them because he had noted that they
relaxed arterial spasm. His conception of how they did good in cases
of angina pectoris was that in such patients there was a spasm of the
coronary bloodvessels, and as a result the heart muscle suffered from
a material diminution in its blood supply. The exact cause of the
pain in angina is not known. Various hypotheses have been advanced
but none have obtained general acceptance. Fred M. Smith1 carried
out some experiments on dogs to throw light on the action of the nitrite
on the coronary vessels. The action of nitroglycerine on the collateral
circulation between distal branches of the left coronary artery was
studied in 15 dogs. In 5 the area of cyanosis that appeared distal to
the point of closure of one of these vessels definitely faded, following
the administration of nitroglycerine. In 6 the results were question-
able, and, in 4, they were apparently negative. The observations in
the former 5 indicated that there was a communication with the adja-
cent vessels which was dilated by the nitroglycerine. In the latter
10 it was concluded that very little collateral circulation existed.

In 14 dogs the action of sodium nitrite was determined. In 6
there was a definite increase in the outflow. In 3 the rate remained
about the same, and in 4 it was decreased.

It would appear that this study does not throw much light upon
the question.

Hare,2 in commenting upon the experiments, states that whatever
the explanation may be, the fact remains that these drugs give us the
best results at the bedside, and it remains for experimental investigation

1 Archives of Internal Medicine, December, 1921.

2 Therapeutic Gazette, 1922, p. 315.

364 LANDIS: THERAPEUTIC REFERENDUM

to reveal how they act if Brunton's original explanation is, as some
think, inadequate or incorrect.

Orthoform. Rosenbloom1 states that it is not generally known that
the external application of orthoform can lead to an alarming general-
ized dermatitis. He reports a case in which the application of a 5 per
cent orthoform ointment caused this condition. The scalp and face
were involved. The dermatitis was accompanied by marked edema of
the tissues, especially of the face, where it resembled that occurring
in glomerular nephritis. The condition was produced a second time
in the same patient. Rosenbloom cites a similar occurrence reported
by Bastedo, the ointment being applied to the hand. In this case a
recurrence was also produced by a second application.

Rosenbloom raises the query as to whether anesthesin and profesin,
nearly related to orthoform, are capable also of causing a dermatitis
in certain cases.

Oxygen. Until the introduction of the so-called open-air treatment
of pneumonia, oxygen was almost universally used in the treatment
of that disease; particularly in those cases with cyanosis and difficulty
in breathing. With the popularization of fresh air, the oxygen tank
practically disappeared. During the last few years the therapeutic
uses of oxygen have received a good deal of attention. This may be
ascribed, in great measure, to the remarkably good results obtained in
cases of gas poisoning from the inhalation of oxygen.

A marked reduction in the oxygen intake results in imperfect aera-
tion of the arterial blood. This is well shown in mountain climbing,
ballooning and aviation. The physiologic effects of imperfect oxygena-
tion of the blood are, periodic breathing, nausea, headache and impaired
circulation. In addition, there may be serious progressive damage to
the central nervous system, heart and other organs. These latter
changes are said to be entirely due to lack of oxygen.

An experiment of Barcroft's is cited by Barach. He lived for five
days in a chamber in which the pressure of oxygen was lowered until
his oxygen saturation at rest was 88 per cent (normal, 95 per cent).
He then experienced the effects of mild anoxemia. His pulse rose from
56 to 86, he was nauseated, racked with headache and suffered from
visual disturbances and vertigo. He became faint on exertion.

As the arterial saturation of patients ill with pneumonia frequently
falls much lower than that experienced by Barcroft, it demonstrates
that the ill-effects of anoxemia must be an actual accompaniment of
clinical disease.

Summarizing, it might be said that the disturbance of the gastro-
intestinal system is manifested by nausea, vomiting and diarrhea;
the respiratory system by periodic respiration, and later by rapid, shallow
respiration; the circulatory system by a constant and progressive
increase in the pulse-rate and in the end by a fall in diastolic pressure
and cardiac failure; the central nervous system by headache, visual
disturbances, irrational states and delirium and, finally, coma and
death.

1 Journal of the American Medical Association, January 28, 1922.

OXYGEN 365

Barach1 states that oxygen failed in the past as a therapeutic agent
largely because of the absence of an ideal method of administering it.
There is no commonly available method that can supply to the patient
an effective concentration of oxygen without in some degree interfering
with his comfort. The apparatus most widely used in this country
and in England, the tube and funnel, adds less than '2 per cent oxygen
to the inspired air, whereas from 40 to 70 per cent is needed.

The effects of oxygen in the treatment of pneumonia have been studied
by Barach and Woodwell.2 These observations were conducted on 11
patients with lobar pneumonia, each of whom had an arterial anoxemia
at some stage of the disease, and 4 patients with bronchopneumonia, '1
of whom had an arterial anoxemia.

Barach3 states that the disease in which acute anoxemia occurs with
the greatest frequency and with the greatest severity is pneumonia,
and it is here, therefore, that oxygen therapy is most urgently indi-
cated. The use of oxygen can be expected to remove, or diminish,
the ill-effects of acute anoxemia, and in that way to improve the patient's
chances of recovery, and at times directly avert death. The clinical
guide to its use is the presence of cyanosis. Barach states that in
pneumonia cyanosis has been said to run parallel to the degree of
arterial anoxemia. It is to be borne in mind, however, that this
applies only to patients without anemia.

The duration and frequency of administration are problems dependent
on the individual patient and the resources at hand. It would seem
theoretically desirable to keep the patient free from cyanosis as many
hours of the twenty-four as possible. In very severe cases it may be
necessary to give oxygen continuously. In less severe cases benefit
may be derived from oxygen administered at frequently repeated
intervals. The signs which should be borne in mind, and which usually
reflect improvement, are: (1) The degree of cyanosis; (2) the pulse-
rate; and (3) the mental condition of the patient.

The degree of cyanosis is, with some exception, the most trustworthy
clinical guide in the oxygen treatment of pneumonia. If the cyanosis
fails to . clear up the prognosis, in Barach's experience, is distinctly
worse. On the other hand, the prognosis is much improved when the
cyanosis clears up under the use of oxygen.

Carefully noting the pulse-rate is also important. Even in normal
persons the inhalation of oxygen causes some slowing of the pulse-rate.
In cases of pneumonia which react favorably to oxygen the pulse-rate
is decreased to a much greater extent. Barach states that the reason
for this presumably is that anoxemia is itself the cause of rapid heart
action. On the other hand, the respiratory rate is usually unaffected;
only occasionally is it slowed, subjective dyspnea does not seem to be
due to oxygen want, nor is it usually relieved by the inhalation of
oxygen.

1 Journal of the American Medical Association, August 26, 1922.

2 Archives of Internal Medicine, October, 1921; Barach: Loc. cit.

3 Loc. cit.

366 LANDIS: THERAPEUTIC REFERENDUM

In addition to these effects, the mental condition becomes more alert
and clearer.

In the cases studied by Barach and Woodwell1 the most consistent
changes in the clinical condition were the clearing of the cyanosis and
slowing of the pulse-rate. The respiratory rate was slowed sometimes,
but the dyspnea was not usually relieved. The mental condition was
frequently improved.

Their experience indicated that oxygen inhalation for a half hour
was sufficient in the mild or moderate cases of anoxemia to elevate
the arterial saturation and cause clinical improvement. In the severe
cases one to two hours was necessary. The effect of a single adminis-
tration was, in the main, temporary. The effect of repeated and pro-
longed administration produced persistent beneficial change in the
oxygen saturation of the blood, the pulse, breathing, color, comfort
and mental condition of the patient.

In cardiac insufficiency the arterial saturation varies from 95 to 75
per cent (normal, 95 per cent). The effects of oxygen in 7 cases of
cardiac insufficiency were studied by Barach and Woodwell.2 Arterial
anoxemia was present in all, and stagnant or venous anoxemia in all
except 1. The arterial anoxemia of acute bronchitis and emphysema,
occurring in cardiac insufficiency, was fully relieved by oxygen inhala-
tion and the venous saturation was correspondingly elevated. Also,
in cases complicated by widespread pulmonary edema the relief of
arterial anoxemia was accomplished in from forty-five minutes to two
hours.

As a result of their observations in these severe cases, Barach and
Woodwell state that the relief of the cyanosis and the slowing of the
pulse were the outstanding objective changes. The blood-pressure,
vital capacity, arterial and venous carbon dioxide content, urinary
excretion and rate of respiration showed no definite change from short
periods of oxygen inhalation. The electrocardiogram showed con-
sistent changes in 2 cases of right bundle branch block, no change in
one uncomplicated case of auricular fibrillation. Subjectively, the
patients usually said they felt more comfortable or that their breathing
was better, but they were rarely enthusiastic.

In a third paper Barach and WToodwell3 report 2 cases of lethargic
encephalitis, in whom there was an extreme type of shallow breathing
attended with deep cyanosis and coma. The arterial blood was
markedly deficient in oxygen and contained an excess of carbon dioxide.

Inhalation of oxygen greatly relieved the arterial anoxemia, but was
without effect on the steady accumulation of carbon dioxide. The
circulation was strikingly improved in the beginning as a result of the
relief of the anoxemia, but, later, progressive cardiac failure occurred,
apparently related to the carbon dioxide retention. They believe it is
evident that shallow respiration, if extreme, interferes not only with
oxygen absorption but with carbon-dioxide elimination. It also seems
probable that a terminal involvement of the respiratory center in
lethargic encephalitis is at times the cause of death.

i Loc. cit. 2 Ibid. 3 Ibid.

PHENOLPHTHALEIN 367

Barach1 states that the great problem, at present, in oxygen therapy
is an efficient method of administration. As mentioned above, only
about 2 per cent of oxygen is inhaled with the method commonly
employed in this country and England. A mixture of air which con-
tains between 40 and 00 per cent of oxygen seems desirable. Less than
10 per cent may not be effective and more than 70 per cent may be
harmful. Barach states that an oxygen chamber is the ideal thing,
but it is impracticable for widespread use. The available methods at
present in use are face masks, an insufflation apparatus and the oxygen
tent of Leonard Hill. A method recently devised by Yandell Hender-
son is the best available, in Barach's opinion. He gives a full descrip-
tion of its use in the Archives of Internal Medicine for October, 1921.
He states that the apparatus can be secured from Mr. Warren E. Collins,
584 Huntington Avenue, Boston, Mass.

Ouabain. Uibierre2 recommends the use of ouabain in cases of
cardiac insufficiency, due to lack of tone in the myocardium, especially
the left ventricle, even when there is marked albuminuria and insuffi-
ciency of the kidneys. The drug should be given cautiously, with the
patient in bed and on a salt-free diet. He cautions against using the
ouabain until at least eight days after digitalis has been given. On
the other hand, digitalis can follow the ouabain, with favorable results,
especially from the standpoint of diuresis.

Phenol (Carbolic Acid). The treatment of erysipelas by means of
the local application of phenol is recommended by Porter.* He applies
95 per cent pure phenol on a cotton-wool swab over the involved area
and for half an inch beyond. It is left on until the purplish area of
the inflamed skin is replaced by a complete whitening of the skin.
This must not be allowed to proceed to complete blanching, and, when
large areas are involved, only a portion must be painted at one time.

The second step consists in going over the blanched area with swabs
saturated with methylated spirit. The alcohol must be laid on until
the whitened area again becomes pink. Afterward, other areas should
be treated in the same way until the whole operation is completed in
one sitting. The later treatment consists in the application of a dressing
moistened with simple saline solution or mercuric chloride, 1 to 20,000.

Phenolphthalein. Skin eruptions following the use of phenolphthalein
as a laxative are reported by Wise and Abramowitz.4 In 5 cases
observed by them there was a peculiar polychromatic eruption on the
skin, with bullous, vesicular and eroded lesions of the mucosa? and
genitals. The cutaneous lesions leave pigmented areas which persist
for months and even years. They flare up after taking the drug and
usually affect the same sites as in preceding attacks. The eruption
exhibits many points of similarity to those resulting from antipyrine
and arsphenamine.

1 Loc. cit.

2 Bulletins de la Societe Medicale des Hopitaux, April 28, 1922.

3 Indian Medical Gazette, June, 1921.

4 Archives of Dermatology and Syphilology, March, 1922.

368 LAND1S: THERAPEUTIC REFERENDUM

Corson and Sidlick1 report a case in which the prolonged use of
phenolphthalein caused an urticarial rash. In both articles quoted
there are numerous references to similar cases in which phenolphthalein
used as a laxative caused skin changes. They also call attention to
the fact that the text-books make no mention of such an occurrence.

Phosphorus. The present enthusiasm for dietary fads and the alleged
necessity of seeing that one's food contains the necessary vitamins and
sal£s has caused some to forget that the diet to which man has long
been accustomed contains all the needed ingredients. Some years ago
a lay dietitian took me to task because I did not know how much phos-
phorus a certain group of children were getting. It is, therefore,
comforting to note that Blatherwick and Long2 present data which
indicate that the vegetables in common use are capable of furnishing
sufficient phosphorus and calcium to meet the maintenance needs of
man.

In the treatment of phosphorus poisoning, Atkinson3 states that
liquid petrolatum given within an hour after taking the poison furnishes
complete protection against the onset of harmful symptoms. It is
physiologically inert and acts entirely by reason of its physical proper-
ties. He suggests that inasmuch as it delays absorption from the
intestines, it might be used to advantage in all poisons.

Pituitary Extract. Physical defects due to abnormal anterior pituitary
secretion are divided by Scott and Broderick4 into those of preadoles-
cence and postadolescence. The former are chiefly defects of growth
and development, and the latter chiefly of function.

They state that while the thyroid tells more on the brain and nervous
development, the pituitary effects osseous and sexual, although no fast
line can be drawn between the two influences. Scott andBroderick point
out that very often the slow developing, dull adenoid type improves
rapidly under the use of thyroid as far as intellect is concerned, but the
body and limb growth falters. In such cases a combination of thyroid
and pituitary does excellently. In girls, especially, the intellectual life
may be active and even brilliant, but the uterine and ovarian develop-
ment are almost standing still, unobserved and untreated. Girls of
this type usually grow up sex failures. Never advancing beyond
rudimentary growth of uterus and ovaries, they swell the ranks of the
disappointed, the sterile and the nervous invalids.

They often begin to menstruate at thirteen or fourteen years, and go
on for a year perhaps; then comes irregularity or complete cessation.
Scott and Broderick believe that this state of things, when not due to
manifest anemia, points almost conclusively to hypopituitarism, and
can be helped wonderfully by anterior pituitary medication. It should
be given in good doses for two or three years, or until healthy menstrua-
tion is well established. Under its influence the pelvic organs develop
as Nature demands.

1 Journal of the American Medical Association, March 25, 1922.

2 Journal of the Biological Chemistry, May, 1922.

3 Journal of Laboratory and Clinical Medicine, December, 1921.

4 Practitioner, October, 1921.

PITUITARY EXTRACT 369

They also point out that children of both sexes, who have enuresis,
often get well under the use of thyroid, hut there are failures too, and
in these the combination of the two gland extracts will often succeed.
Cases especially demanding pituitary are those in which there are
subnormal skeletal growth and osseous development.

Jacoby1 considers that the chief factor in the production of female
sterility is a dysfunction of the ovary. Careful study will also show
that in addition there is usually a deficiency of the pituitary, thyroid
or suprarenals. Dysfunction of one or the other of several of these
glands produces conditions which make it impossible for pregnancy to
successfully occur. Jacoby points out the uselessness of dilating,
curetting or otherwise operating on the great majority of these patients.
In the absence of any obvious gross pathologic conditions, a careful
study of the endocrine system should be made in order to determine,
if possible, the gland extract needed.

One of the most successful uses to which pituitary extract has been
put is in the treatment of diabetes insipidus. The only objection to
this treatment has been the inconvenience of using the extract hypo-
dermically. Blumgart2 reports the use of pituitrin intranasally. In
a case of diabetes insipidus, pituitrin applied intranasally checked both
the polyuria and polydipsia. In 3 additional cases the intranasal use
of pituitrin was found as satisfactory as hypodermic injections in
reducing the fluid intake and urinary output to an approximately normal
level.

Rees and Olmstead3 studied the possibility of finding a satisfactory
method of administering pituitary by mouth. They considered reduced
expenses and the increased inconvenience as the principal factors. The
details of a case of diabetes insipidus are given, in which various types
of treatment were tried. They found that by giving desiccated poste-
rior-lobe substances in salol-coated capsules the polyuria and poly-
dipsia were as effectively controlled as with hypodermic injections of
pituitary extract.

In another study on the oral administration of pituitary extract,
Hamill4 found that animal experiments prove that administration by
mouth causes the characteristic internal contractions. Absorption
takes place from the stomach and is more rapid when the stomach
is full and actively digesting. Large doses produce colicky contrac-
tions of the intestine and vomiting. This experimental observation
harmonizes closely with clinical evidence. Hamill, therefore, advises,
in view of the rapid absorption from the stomach and the fact that the
intestinal juices rapidly destroy the active principle, it would appear
preferable that pituitary extract should be administered in solution
and after meals.

Pituitrin in Obstetrics. Shortly after pituitrin was introduced
into obstetrical practice, not a few fatalities were reported from its

1 Medical Record, February 11, 1922.

2 Archives of Internal Medicine, April, 1922.

3 Endocrinology, March, 1922.

1 Proceedings of the Royal Society of Medicine, June, 1921.

370 LANDIS: THERAPEUTIC REFERENDUM

use. This occasionally resulted in rupture of the uterus. Fortunately,
reports of this accident are becoming rarer. That the careless use of
pituitrin still occasionally prevails is shown by the report of a case by
M. A. Dorland.1 He was called to see a woman who had been con-
fined by a midwife. The patient, an octipara, had been in labor about
eleven hours and was progressing normally when the midwife, becoming
fatigued, administered hypodermically 0 5 cc of pituitrin and followed
this in an hour by a second dose. In about ten minutes after the
second injection the patient experienced a very painful contraction,
during which the uterus evidently ruptured. The patient was removed
to a hospital and the abdomen opened. The child, weighing 11 pounds,
was dead. The uterus was found to be ruptured throughout the
attachment of the broad ligament nearly to the fundus. The woman
died forty-eight hours later.

The contraindications to the use of pituitrin in obstetrics have fre-
quently been stated in previous issues of Progressive Medicine, but
they bear repeating. Mendenhall2 epitomizes them as follows:

1. Undilated cervix.

2. Disproportion between passenger and passage.

3. Abnormal presentation or position.

4. Presence of obstructing tumors.

5. Scar from previous Csesarean or myomectomy.

6. Heart disease of mother.

7. Eclampsia.

8. Atheroma.

9. Threatened asphyxia of child in utero.
10. Contractions which are already strong.

If this latter point alone were constantly borne in mind there would
be far less use of pituitrin and consequently very much less damage
done. So long as the patient is having fairly strong and frequent
pains there can be no excuse for giving her a drug that will increase
them in frequency or strength when attended with such great dangers.

In regard to pains which are weak and are declining, in addition to
the aboye, Mendenhall states that we may be said to have indications
justifying the cautious use of small doses of pituitrin (2 to 3 minims),
remembering that episiotomy or low forceps, or both, are usually better
obstetrics.

In the matter of dosage, Johnson3 states that when he first began
the use of pituitrin in obstetrics he gave it in doses of 1 cc, and only
to multipara? who were nearing the end of labor. He soon found, how-
ever, that the resulting expulsive efforts were unnecessarily violent.
He then adopted the plan of not giving more than 2 minims as an initial
dose, and in some cases 1 minim or even 0.5 minim. He now employs
pituitrin in these doses in primipane as well as multipara^, and in the
first, second or third stage of labor, and for the induction of labor. If
it is administered with a tuberculin syringe, which enables one to
accurately measure the dose, no harm will result.

1 Journal of the American Medical Association, January 21, 1922.

2 Indianapolis Medical Journal, August, 1921.

3 Medical Record, March 4, 1922.

PITUITARY EXTRACT 371

[f 1 minim docs not produce a reaction in fifteen minutes a little
larger dose may be given, and, if the contractions become too strong
or too frequent, they can be modified promptly by a hypodermic injec-
tion of heroin or ;i few whiffs of ether,

Johnson feels that it is wrong to withhold this aid to labor because
there have been accidents due to carelessness or ignorance.

Most obstetricians hold the view, however, that pituitrin, in the
absence of certain definite contraindications, should be used in the
third stage of labor only. From his own experience, Hefferman1 believes
that pituitrin administered at the beginning of the third stage of labor
is effective in aiding a prompt and complete detachment and expulsion
of the placenta and membranes.

Tetanus uteri, with incarceration of the placenta, does not occur
from the careful use of pituitrin in the third stage of labor. Further-
more, pituitrin tends to prevent relaxation of the uterus and post-
partum hemorrhage during and after the third stage of labor. Manual
removal of an adherent placenta should not be attempted until at least
three doses of pituitrin have failed to produce detachment.

Brodhead and Langrock2 believe that the only drawback to the use
of pituitary extract, at the beginning of the third stage of labor, is
the possible existence of irregular or hour-glass contraction of the
uterus. Inasmuch as this complication occurs independently of the
use of pituitary extract, further investigation will be necessary to
determine whether this complication is directly attributable to the
method or not.

Ryder3 has studied 100 cases in which 1 cc of pituitary extract was
given at the beginning of the third stage of labor and 100 cases in which
it was not used. In none of the 100 cases in which the pituitary extract
was employed was there any untoward effect.

The extract tends to cause spontaneous expulsion of the placenta,
lessens the amount of blood lost and makes the guarding of the fundus
during the third stage easier, as little stimulation of the fundus is
necessary to keep it contracted. It does not, however, do away with
the necessity of watching or holding the fundus. Not only must the
fundus be well contracted, but it must be kept from riding high, other-
wise unobserved bleeding may occur into the membranes already parti}'
expelled into the vagina.

Pouliot4 refers to the use of pituitary extract in the posterior varieties
of vertex presentation. (Abnormal presentations, as a rule, contrain-
dicate the use of pituitrin.) In these posterior presentations, Pouliot
states that expulsion is always slower than with the anterior varieties.
With multipara?, labor usually lasts four or five hours longer, and with
primiparse it is considerably longer than this. Pouliot states that the
rule that pituitary extract should not be given until the period of
expulsion, waiting until the os has become dilated, does not apply in

1 Boston Medical and Surgical Journal, October 13, 1921.

2 American Journal of Obstetrics and Gynecology, February, 1922.
•! Ibid., July, 1921.

4 Revue Frang. de Gynecologic et d'Obstet., March, 1922.

372 LANDIS: THERAPEUTIC REFERENDUM

these cases. His belief is that the indication is not the diameter of the
os, but whether the inferior segment is becoming thinner and more
supple. He describes 9 cases of O. I. P. presentation, illustrating how
the pituitary almost instantly stimulates the deficient contractions.
In multipara1 delivery proceeded rapidly and easily. In primiparse the
results were less constant and less immediate, but still they appreciably
shortened the labor and usually rendered forceps unnecessary.

Pouliot states that in 100 deliveries under pituitary treatment,
only 1 infant was affected and that but very slightly. He employs
1 cc and, if this proves effectual, he repeats it after the effect is quite
exhausted, even in an hour. He emphatically warns against a second
injection if the first has failed, and, furthermore, he emphasizes the
fact that only the obstetrician should administer the pituitary.

Norgate1 has used pituitrin in 36 cases of inoperable cancer. He was
led to this use of the pituitrin from the observation that pituitary extract
(posterior infundibular) was effective in controlling the intestinal bleed-
ing.

He first tried it in a case of sudden and severe hemorrhage from an
extensive epithelioma of the tongue. One cubic centimeter was injected
into the tongue muscle. All bleeding stopped at once and there was
no repetition. Weekly injections into the tongue for three months
resulted in marked improvement. The patient put on weight and the
cachexia disappeared. Later, however, he died from a metastatic
growth in the liver.

Norgate sometimes gives the injection directly into the cancer; in
other cases, placing it as near the growth as seems practicable. He
noted that in twenty seconds the patients experience severe pain in
the back or abdomen, and a sensation of squeezing the growth, followed
by an anemia, which may be alarming, and a weak pulse. The condi-
tion may be relieved by the use of brandy, but is preferably to be
untreated.

According to Norgate, the use of pituitrin in these cases nearly
always brings about an increase in appetite and strength and weight.
Norgate states there also seemed to be a delay in the onset of secondary
gland involvement and a tendency toward abortion of the growth;
nor was there observed secondary deposits in other parts of the body.
The use of pituitrin is especially commended as a means of controlling
hemorrhage.

The effect of extract of the posterior lobe of the pituitary on basal
metabolism in normal individuals and in those with endocrme disturb-
ances has been studied by McKinley.2 He draws the following
conclusions:

1. Normal persons responded quite constantly with increased basal
metabolism following the subcutaneous injection of pituitary extract.

2. In a small series of cases with hypothyroidism the basal metab-
olism was diminished rather than increased, which suggests that
pituitary extract is effective in accelerating heat production only in
the presence of a normally functioning thyroid gland.

1 British Journal of Surgery, April, 1922.

2 Archives of Internal Medicine, December, 1921.

POTASSIUM PERMANGANATE 373

3. In four cases with subnormal basal metabolism, in which clinical
evidence of myxedema was lacking and preponderance of influence of
endocrine glands other than thyroid was suggested, the positive response
to pituitary extract was present.

4. The increased acceleration of basal metabolism in a group of
normal individuals following the subcutaneous injection of pituitary
extract one week after an injection of thyroxin is interpreted as sug-
gesting a synergic action between thyroxin and pituitary extract.

Potassium Nitrate. While admitting its use is somewhat empirical,
Pennington1 recommends the use of potassium nitrate in the treatment
of osteomyelitis. The salt is mixed with oats (10 to 60 grs. to the ounce
of oats) and sufficient hot water added to reduce it to a poultice-like
mass. This is then spread over the affected area to the thickness of
about three-sixteenths of an inch, then with oiled silk, paraffine paper
or a rubber dam, and over this a bandage. The poultice is applied
well beyond the area involved.

A case of poisoning from the internal use of a mixture of potassium
nitrate and sulphur is reported by Windmueller.2 The patient was
advised by a friend to take equal parts of sulphur and saltpeter in
teaspoonful doses four times a day. He followed this treatment for
twenty-six days, taking approximately 10 gms. of potassium nitrate.
From a man who was apparently healthy, he appeared with sunken
eyes, marked loss of weight and very nervous. He complained of intense
muscular pain, which was aggravated by motion or touch, similar to
that encountered in trichinosis.

The blood findings showed a severe grade of anemia; hemoglobin,
50 per cent; red cells, 290,000; leukocytes, 8500. There were a few
poikilocytes.

The urine was reduced to 20 ounces daily, and contained albumin,
a few hyaline and waxy casts and a few red blood cells. The man
died, but no autopsy was obtained.

Windmueller does not believe that the sulphur played any part, as
it is frequently employed, even in children, as a laxative. Fairly large
doses of potassium nitrate have caused acute poisoning and even death.
He, therefore, believes that following the rule that all substances which
cause acute poisoning will be followed by chronic poisoning with the
successive administration of subtoxic doses probably applies in this
case.

Potassium Permanganate. The external application of this antiseptic
in the treatment of smallpox is reported by Balfour.3 He states that
the method was originally introduced by Dreyer, of Cairo, in 1910,
but apparently has been forgotten. He quotes Bender, of Breslau, as
stating he regards it as superior to every other therapeutic agent in
smallpox. The method is as follows: When the patient is admitted
to the hospital his whole body is painted over with a freshly prepared
saturated solution of permanganate of potassium (5 per cent). On

1 Medical Record, December 31, 1921.

2 Journal of the American Medical Association, September 10, 1921.

3 Indian Medical Gazette, December, 1921.

.374 LANDIS: THERAPEUTIC REFERENDUM

each successive day the same solution is applied unless the skin is found
too sensitive, in which case a weaker solution is employed, one of 1.5
per cent being often suitable.

Dreyer had two objects in view: (1) To color the skin and thereby
obtain an effect similar to that which the Finsen red-light treatment
is said to produce; and (2) to secure a disinfecting and deodorizing
action.

Reports by those who have employed this method seem to indicate
that this line of treatment, if employed early, is of much service in
lessening the suppurative process and adding to the patient's comfort.
It is also said to prevent complications, the formation of bed-sores
and the occurrence of general sepsis. Septic fever is thus avoided and
the recovery rate improved. Furthermore, as the suppuration is
mitigated the pitting of the skin is reduced.

Procaine. The occurrence of dermatitis from the use of procaine
is reported by R. C. Morris.1 He states that in a dental clinic, in
which nerve-blocking is frequently employed, one operator in every
twelve showed, as the result of using a hypodermic syringe that would
leak in the barrel, allowing the 2 per cent solution of procaine to come
in contact with the fingers, a drying, cracking skin that would exfoliate,
leaving the true skin red, hypersensitive and painful.

Protein. Fddgren,2 in writing on the use of intram use ular injections
of milk, states that a large injection prolongs the coagulation time of
the blood, while a small injection accelerates it. He states that there
is practically no danger of anaphylaxis if a small preliminary injection
is made, and there need be no fear of a pronounced reaction if a toxin-
free milk is used, but one should be cautious in those with heart disease
or those of advanced age. Kidney disease does not seem to be a
contraindication, as he has seen albumin disappear from the urine after
the use of the protein.

Buschke3 warns that latent tuberculosis is apt to flare up if protein
therapy is employed. The employment of protein therapy in the
treatment of arthritis should be resorted to, in Cowie's4 opinion, only
wThen all possible foci of infection have been considered. He seldom
uses a dose under 500,000,000 (dead typhoid bacilli), and children,
as w7ell as adults, have received billion doses. He believes it is per-
fectly safe to fix the average dose for child and adult at 100,000,000
dead typhoid bacilli, and the maximum at 500,000,000. Reactions are
usually sharp and include the unpleasant symptoms of nausea, head-
ache and sometimes vomiting. He has never had an untoward result.
The dose may be increased beyond the limits given above in certain
individuals and in certain types of cases.

He considers that cardiac decompensation, acute cardiac difficulties
and conditions associated with hyperthyroidism should be regarded

1 Journal of the American Medical Association, October 22, 1921.

2 Hygiea, July 16, 1921; Abstract, Journal of the American Medical Association.

3 Medizinische Klinik, June 11, 1922.

4 New York State Journal of Medicine, November, 1921.

PULSATILLA 375

as contraindications. Cowie states that il is thought that intravenous
protein injections increase gastro-intestina] peristalsis; hence the import-
ance of careful consideration before employing them in intestinal hemor-
rhage to increase Mood coagulability.

Although Cowie has had no untoward results, Kross1 regards the
method as being unsafe. He has come to the conclusion that protein
treatment has not increased the resistance of animals to mouse typhoid,
to general peritoneal sepsis, or to pneumonia, and has not enabled
them to overcome infection any better than do the untreated ones.
In fact, the treatment apparently reduced the vitality of the animals,
as is evidenced by their more rapid destruction.

Furthermore, Kross believes that the danger of death from ana-
phylactic shock is such as to stamp this method of treatment as actually
threatening great potential harm. He states that a number of deaths
have occurred shortly after intravenous injections of bacterial sub-
stances, and in 1 case death followed the intravenous administration
of "rheumatism phylacogen." He feels that the utter lack of experi-
mental evidence, and the recognized clinical danger of the procedure,
indicate the need of caution in assuming the therapeutic value of intra-
venous protein injections in the treatment of infections.

In a study of the nature of the action of non-specific protein in disease,
Cowie and Greenthal2 found that the protective action of normal horse
serum precipitated by alcohol was much less than that of untreated
horse serum when injected into guinea-pigs which had received a fatal
dose of diphtheria antitoxin. No protective effect against diphtheria
toxin was observed with the following proteins: Egg white, milk,
guinea-pig serum and rabbit serum. One cubic centimeter of normal
horse serum, when injected subcutaneously into a guinea-pig, will
protect against a fatal dose of tetanus toxin. Cowie and Greenthal
believe the protective action of normal horse serum against soluble
diphtheria toxin is due to natural antitoxin in the serum and not to
the effect of the non-specific protein injected.

Pulsatilla. The use of this drug in the treatment of certain types
of dysmenorrhea is recommended by Coley.3 The cases in which he
prescribed Pulsatilla give a history of this kind: They have pain for
the first day or two of each menstrual period. Sometimes it begins
a day or so before the period. The flow is usually small.

Coley does not use the drug in cases in which the flow is excessive,
lasting six days or more, and attended with the passage of clots, pain
continuing through the whole of the period, or nearly so. Most of the
patients he has treated have been unmarried. Coley does not pretend
to explain the pathology of the condition nor the action of the Pulsatilla.
Relief may be experienced from the beginning, but if not it is almost
certain to eventually succeed in the type of case he describes above.
He has never known it to produce any undesirable effects, or indeed

1 Journal of Medical Research, January-March, 1922.

2 Ibid.

3 British Medical Journal, January 7, 1922.

376 LANDIS: THERAPEUTIC REFERENDUM

any other effect at all than that for which it was prescribed. He uses
the following' formula:

1$ — Tinctura pulsatillae oiv

Spiritus chloroformi oij

Aquae chloroformi q.s. ad. §vi

M. Sig. — Two teaspoonfuls to be taken as soon as menstrual (or premenstrual)
pain begins, and every three hours while pain continues.

Quinine. The intravenous use of alkaloidal quinine in the treat-
ment of 'malaria is recommended by Brahmachari.1 He states that it
possesses very marked antihemolytic properties. The solution is made
as follows: Quinine alkaloid, 5 grs. ; alcohol, 50 minims; ure thane, 3 grs. ;
calcium chloride, 7.5 grs.; glucose, 300 grs.; physiologic sodium chloride
solution, 200 cc; 85 per cent solution of sodium chloride in distilled
water. This solution is alkaline in reaction and is well borne by malarial
patients. Brahmachari states that this solution given intravenously
does not lead to such a profound fall of systolic blood-pressure as is
observed in the case of quinine bihydrochloride and circulatory dis-
turbances are less marked. Ten cubic centimeters of this solution
(equivalent to \ gr. of quinine alkaloid) given intravenously into rabbits,
weighing 450 to 470 gms., did not produce any ill-effects. This amount
will correspond nearly to giving 1200 cc of the solution to a man of
average weight.

In another article on the intravenous use of quinine, Brahmachari2
asserts that the amount of quinine bihydrochloride injected into a vein
at the bend of the elbow should not be more thany-^-j gr. per second,
or \ gr. per minute. This will mean that 10 grs. will take twenty
minutes for completion of the injection. Using a dilution of 1 to 300
means that 10 cc will take one minute for injection, and the total
amount given will be 200 cc. Higher amounts of fluid, in a patient
whose blood-pressure is low, is likely to produce pulmonary edema,
which may prove serious in certain cases of pernicious malaria. A
dilution less than 1 to 300 may make it difficult to inject at the rate
of y|"q gr. of quinine per second. In children the rate of injection
should be even slower.

For children under fifteen years of age he suggests that 5 grs., instead
of 10 grs., should be injected in twenty minutes.

Maxcy3 warns that the intravenous use of quinine in the treatment
of malaria is not without danger, and for this reason should not be
employed routinely.

Its proper field of usefulness seems to be upon urgent clinical indi-
cations of two sorts: (1) In cases in which prompt absorption by the
gastro-intestinal tract, following mouth administration, is not to be
expected bacause of violent gastro-intestinal disturbance or other cause,
or in which it is impossible to give the drug by mouth on account of
delirium, coma, etc.; and (2) in cases winch are gravely ill when first
seen by the physician, and in whom it is deemed imperative to secure

1 Indian Medical Gazette, June, 1921.

2 Journal of Tropical Medicine and Hygiene, June 15, 1922.

3 United States Public Health Service, 1922.

QUININE 377

immediate cinchonization. It docs dot seem necessary, nor desirable,
to use the intravenous route of administration in the simple acute or
chronic infections ordinarily encountered, whether tertian or estivo-
autumnal.

A case of quinine poisoning is reported by Leach.1 The patient was
a child, aged three years, who took from twenty to a hundred 2-gr.
quinine pills. The symptoms were vomiting, stupor, twitching of the
muscles around the mouth, combined with a slow shaking of his head
from side to side or up and down, occasional spasmodic contraction of
the flexor muscles of the limbs, flushed face and dilated pupils.

The ingested pills were only partly dissolved. The child recovered.
While no rash developed after this overdose of quinine, the child had
for a year or more previously always developed a rash after a therapeutic
dose of the drug.

Quinidine. In 1914, Wenkelach reported 2 cases of auricular fibril-
lation, in which the normal rhythm was restored temporarily by quinine.
Possibly because attention was diverted from everything else during
the war this observation attracted little notice at the time. In 1918
Prey, studying the effect of various cinchona derivatives on this type
of cardiac arrhythmia, found that quinine had this action to the most
marked degree. Within the past two or three years the action of quini-
dine in auricular fibrillation has attracted a great deal of attention
and the literature on the subject has been extensive. As an editorial
article2 points out: "Rarely has a drug made a stronger or more
dramatic bid for immediate acceptance as a valuable therapeutic
agent than has quinidine in auricular fibrillation. Emerging from its
obscurity, where it was known only to the few as an isomer of quinine,
this compound has suddently leaped into the bright light of popularity,
winning instant applause because of its startling effects in certain
types of cardiac irregularity. To see a heart that has been constantly
irregular for one or two years because of a fibrillating auricle lose its
lawless and rapid beat within a few hours under the influence of a small
amount of this drug, and assume normal rhythm and rate and maintain
these for months, must attract the attention of even the most skeptical
clinician or the most confirmed therapeutic nihilist."

While publications subsequent to the above have somewhat tempered
the enthusiasm, there can be no doubt but that quinidine is a powerful
and valuable agent in certain cases. In common with other efficient
remedies, the present problem is to determine the cases in which it
does good and those in which it fails or actually does harm.

Quinidine is obtained from cinchona bark as a by-product in the
manufacture of quinine, to which it is closely related, being the stereo-
isomer of quinine. Like quinine, it is a protoplasm poison. It affects
protozoa more than bacteria, but less powerfully than quinine. At
one time it was used to some extent as a substitute for quinine because
it was then much the cheaper preparation.

It is usually administered in the form of quinidine sulphate. Com-

1 Journal of the American Medical Association, July 1, 1922.

2 Ibid., December 3, 1921.

378 LAX MS: THERAPEUTIC REFERENDUM

monly, 0.2 gm. (3 grs.) of the salt is given as a preliminary dose and is
repented alter two hours to determine the patient's susceptibility to
the drug. If there are no symptoms following this preliminary dose
therapeutic administration is begun on the following day, when from
0.2 gm. to 0.4 gm. (3 to 6 grs.) is given from three to four times daily,
for one to three days. As a rule, if the establishment of the normal
rhythm can be affected the change occurs after from one to three days'
treatment. The maximum dose per day advised by most observers
is from 1 to 2 gm. (15 to 30 grs.). If toxic symptoms occur the admin-
istration of the drug should be discontinued.

The pharmacology of quinidine is not as yet fully understood. The
general impression, however, is that quinidine and other cinchona
alkaloids are the only drugs known to have this specific effect. The
action of the drug on the heart has been studied by Jackson, Friedlander
and Lawrence.1 They felt that there was nothing unique in the action
of quinidine on auricular fibrillation and that, perhaps, a large number
of drugs which exercise a general depressant action on the cardiac-
muscle would, in all probability, act in a very similar manner. It
appeared to them to be simply a question of selecting a substance of
sufficiently low general toxicity, and one which would be eliminated
from the blood but slowly, in order that a prolonged, mild depression
of the auricular tissue might be produced. The drug undoubtedly
acts on both ventricles and auricles. In their experiments they found
that the fibrillation of the ventricles in perfused hearts was checked
by the temporary addition of small quantities of potassium chloride
solution to the perfusion fluid, indicating that quinidine does not
possess a unique action in this regard. The authors surmise that in
one course it will be found that quinidine acts on the musculature of
the peripheral vessels and, perhaps, even on the skeletal muscles, in a
manner quite similar to that in which it acts on the heart muscle.

It will be recalled that in auricular fibrillation the auricle is no longer
contracted by impulses arising at a single point, but by a never-ending
wave, which passes over and over again through the same muscular
channels— what Lewis has aptly described as a circus action. Lewis,
Drury2 and others, and Hoffman have shown that quinidine reduces
the excitability of the auricular muscle, but that the most striking
action upon the auricle is a lengthening of the refractory period. In
other words, that fraction of time in which the wave is traveling leaves
the muscle behind it for some time incapable of response. They,
therefore, believe that quinidine emphasizes or prolongs this period
50 per cent, or more, delaying the recovery of the tissue so that they
do not react to the following contraction wave. Furthermore, either
as a result of this or other influences, it slows conduction of the auricle.
Because it impairs contractile power it is probably dangerous when
the ventricle is weakened by disease.

In using quinidine in cardiac condition, it must be borne in mind
that it is not without some unpleasant, and even dangerous, effects.

1 Journal of Laboratory and Clinical Medicine, March, 1922.

2 British Medical Journal, 1921.

QUININE 379

Some patients appear much more suceptible to its toxic effects than
others. The untoward symptoms are nausea, vomiting, convulsions,
palpitation, headache, faintness and sloughing. In most cases, after
administration of tlie drug, the pulse increases in rapidity before the
normal rhythm is established. In some eases the effect of the drug is
restricted to this alteration of rhythm. In a few eases such serious
results as rapid ventricular tachycardia have been initiated during
the course of therapy. Toxic effects may appear after the establishment
of a normal rhythm.

Eyster and Fahr,1 in pointing out some of the dangers of quinidine
treatment, state that "In most cases, perhaps in all, disturbances of
rhythm occur during the transition stage between auricular fibrilla-
tion and sino-auricular rhythm. The most characteristic and frequent
of these transition rhythms is rapid, regular heart action (auricular
tachycardia, "auricular flutter"), occurring either alone or in periods
interspersed with periods of fibrillation. These intermediary stages may
occur even when the normal rhythm is not subsequently restored, as
in the first case presented here. It is apparently the result of these
stages of transition, in which the dangers of the treatment lie. While
acutely developing auricular fibrillation undoubtedly causes considerable
mechanical deficiency of the heart, and is probably not infrequently
the immediate cause of cardiac decompensation, the heart may com-
pensate for this as it does for valve injury, particulary when it is
assisted by the protective influence on ventricular stimulation of digi-
talization. That the removal of this compensated auricular fibrillation
under the action of quinidine in producing transition rhythm may
destroy clinical cardiac compensation, is illustrated by one of the
cases they report. Possibly also the contractility of the ventricular
muscle is reduced by the drug. The case again becomes critically ill,
and if restoration of the normal sino-auricular rhythm fails, as it
apparently so frequently does in the older and more severe forms of
chronic heart disease, the best that can be hoped for is a tedious resto-
ration of compensation with another period of cardiac failure with
its attendant permanent damage to be charged to the quinidin treat-
ment. On the other hand, when auricular fibrillation is unassociated
with valvular or severe myocardial damage and with no history of
severe circulatory failure, the cardiac reserve is able to carry the circu-
lation through the periods of "transition rhythm" with only transitory
circulatory deficiency."

Ritchie2 has met with unpleasant results. It may increase the
ventricular rate, it may set up multiple ventricular extrasystoles, and
there is also, in his opinion, some danger of embolism from a dislodged
clot in the auricles. This latter danger is also emphasized by Sir
James MacKenzie, who points out that in auricular fibrillation the
failure of the auricle to contract properly not rarely results in the
formation of clots, and that these clots may remain in situ while the
auricle is fibrillating only to be dislodged and sent into the general

1 Archives of Internal Medicine, January, 1922.

2 British Medical Journal, May 20, 1922.

380 LANDIS: THERAPEUTIC REFERENDUM

circulation, producing infarcts, if the auricle regains its normal con-
tractility.

All recent communications are opposed to the opinion expressed by
Cheinisse,1 that quinidine may be regarded as free from serious danger,
or that of Pardee,2 who, while admitting that we do not as yet know
how to handle it properly, states that it is not necessary to have the
patient in bed when the drug is given if the doses are not too large.
He states that he has seen no harm result from giving it to 18 ambulant
patients. On the other hand, Wolferth3 points out that this form of
therapy is still in the experimental stage and emphasizes that close
observations should be maintained, the patient being in a hospital or
under the care of a well-trained nurse. The same opinion is expressed
by Eyster and Fahr4 and by Lewis,5 the latter stating that it is a treat-
ment emphatically for the wards rather than for use in an outpatient
department.

Lewis believes the usefulness of the drug from the clinical standpoint
is limited. The chief limitation consists in the early and very frequent
resumption of auricular fibrillation. In not a few patients the restored
normal rhythm lasts but a few days or a week, and fibrillation returns
again and again after successive periods of treatment.

In others the normal rhythm is maintained for a few weeks or months;
a few cases have been maintained for six months or a year. In the
last group it must be judged an unqualified success, but in proportion,
as from case to case, the return of fibrillation is less delayed, so the
remedy becomes less practicable as a remedy. He deprecates the
general use of the drug, and urges that it should be employed only
under strictly controlled conditions.

Lewis believes that the value of quinidine has so far been greater
in adding to our knowledge of fibrillation of the auricles than it has
been in therapeutics. It has taught as many important facts, and
among the most notable is that the hearts which display chronic auricu-
lar fibrillation are capable of beating normally— a quality hitherto in
doubt. It has also taught us that the cause which predisposes to
fibrillation, or at first initiates fibrillation, is maintained in the chronic
state.

Sir James MacKenzie6 is not yet fully convinced that quinidine will
do all that is claimed for it, pointing out that many remedies have on
their introduction aroused great expectations which have not been
fulfilled, and that some that are potent for good have also suffered
from indiscriminate use and so have become unjustly discredited.

As already stated, one of the chief problems in regard to the use of
quinidine is the type of case in which it should be used. Hamburger
and Priest7 suggest the following types in the order of their decreasing

1 Presse m6dicale, September 17, 1921.

2 Medical Record, December 17, 1921.

3 American Journal of the Medical Sciences, 1921, 162, 812.

4 Loc. cit.

5 American Journal of the Medical Sciences, June, 1922.

6 British Medical Journal, 1921.

7 Journal of the American Medical Association, July 15, 1922.

RADIUM AND ROES THEN-RAY 381

suitability for quinidine treatment: (a) Patients with acute fibrilla-
tion or recurrent paroxysmal fibrillation; (6) patients with fibrillation
of short duration without history or findings of heart failure or embol-
ism; (c) patients with signs and symptoms of early or apparent heart
failure, but without evidence of advanced heart failure.

Fred M. Smith1 found the treatment most successful in those in
whom auricular fibrillation was of short duration and associated with a
good cardiac musculature. In this group, however, the results could
not always be produced.

Wolferth2 points out that the most favorable cases for treatment
are those with: (1) Relatively good heart muscle and at least fair
compensation; and (2) flutter or fibrillation that has been present only
a short time.

Ritchie3 considers that quinidine should not be used in cases in
which there are such signs of cardiac failure as dilatation of the heart,
dropsy or cyanosis.

Hewlett and Sweeney4 are of the opinion that, in view of the possible
dangers associated with the administration to cardiac patients, quini-
dine should be given only after decompensation has been treated by
other methods, and when the patient is kept under careful observation.

Opinion as to the use of digitalis and quinidine in combination is not
in agreement. Starkenstein5 states that the use of quinine and digi-
talis combined is justified if, in connection wTith prolonged digitalis
medication, it is necessary to counteract possible cumulative effects
or other dangers from intoxication. On the other hand, Hewlett and
Sweeney6 assert that combinations of quinidine and digitalis should
probably be avoided. In collections of reported cases of auricular
fibrillation, the number responding favorably to quinidine is about 50
per cent of the total.

Radium and Roentgen-ray. The use of radium is becoming more and
more prevalent. There can be no doubt that there are many, many
individuals suffering from malignant disease past the operable stage,
who have been given great relief from the use of radium. Deaver,7
in an article on radium therapy, with special reference to disease of the
female pelvis, closes with the statement that whatever may be the future
of radium therapy, the fact remains that it is today not the panacea for
cancer, the advent of which is so eagerly being awaited, for in numerous
cases in which it is most needed it has not as yet fulfilled expectations.
It wrould seem that he clouds the issue. No one claims that radium
therapy is perfected, or that it is in anything but the experimental
stage. No one claims that it is a panacea for cancer. What is claimed
is that it has a remarkable effect on malignant growths, so much so,
that there is much more to be hoped for when its effects and the method
of using it are better understood.

1 Journal of the American Medical Association, March 25, 1922.

2 Loc cit. 3 Loc. cit.

4 Journal of the American Medical Association, December 3, 1921.

5 Deutsche med. Wchnschr., March, 31, 1922.

6 Loc. cit.

7 Therapeutic Gazette, July, 1922.

382 LANDIS: THERAPEUTIC REFERENDUM

Knox,1 in refuting the statement of a well-known surgeon that radium
lias proved a failure, and that surgeons were giving up its use and
turning to penetrating roentgen rays in the treatment of malignant
disease, states that this is not true. The real reason for any such
statement lies in the fact that disappointing results have followed
radium in those cases which were quite unsuitable and hopeless. On
the other hand, there are innumerable cases which were hopelessly
inoperable which have been given the greatest relief.

In the treatment of basal-cell carcinoma of the face, Morrow and
Toussig2 state that it is seldom necessary to use buried bare tubes of
radium. Except in the deeply infiltrated and very extensive cases,
surface application is usually satisfactory. In the great majority of
squamous-cell carcinomas the buried tubes, in association with surface
applications, have been helpful. In the case of deep carcinomatous
infiltrations the buried tubes are almost a necessity.

The question of when to operate and when to use radium in dealing
with fibroids of the uterus is considered by Gellhorn.3 He gives the
advantage of radiotherapy as follows:

1. Clinical Cures. These are obtained in wrhat probably constitutes
more than 60 per cent of all cases of fibroids coming under our care.

2. The Element of Safety. In the hands of the expert this method
has no mortality, whereas after operations there is, even in the hands
of excellent surgeons, an average mortality of from 3 to 5 per cent.

3. Morbidity. There is an insignificant morbidity after radiotherapy
which is steadily growing less as the result of improved technic. At
any rate, the patients are spared the mental and physical suffering
that any major operation entails.

4. The Economic Aspect. Radium treatment is not inexpensive;
but as the patients hardly ever remain in the hospital more than two
or three days, the expenses for hospital, nurses and dressings are saved,
so that the total expense connected with radium treatment is consid-
erably below that of operative treatment. Then, too, the patients
are not kept away from their occupation for any length of time, and,
finally, the overcrowded condition of our hospitals is relieved.

He believes the cases in which surgery is applicable are fairly well
defined. Thus, all tumors extending above the umbilicus, and, like-
wise, all large pedunculated, subserous or submucous fibroids should
be operated upon, for in these three classes radiotherapy is likely to
produce a necrosis of the tumors. Cervical fibroids are equally unsuited
for radium, and should be removed surgically. This is also true of
suppurating necrotic or gangrenous tuniors, and those which are under-
going cystic or calcareous degeneration.

The age incidence, in Gellhorn's opinion, is a decisive indication for
operation. This means that, as a rule, women under forty years
should be operated upon rather than exposed to radium. The younger
the patient, the more clearly is operation advisable, as the preservation

1 British Medcal Journal, April 22, 1922.

2 Archives of Dermatology and Syphilology, January, 1!)22.

3 Journal of the American Medical Association, January, 1'JL'L'.

RADIUM AND ROENTGEN-RAY 383

of the menstrua] function and the restoring of fertility are to be borne
in mind.

Gellhora also considers a third group in which either of the two
methods may be used. Rapidly growing fibroids, which may be sus-
pected of malignant changes, may be operated upon or treated with
radium. The latter is safe and is known to rapidly kill the cancer
cells. There is another group in which the fibroid is incarcerated in
the pelvic cavity, and may encroach on some one of the surrounding
viscera. They may be removed surgically, but, on the other hand, they
have been known to shrink rapidly under the use of radium.

Fanre1 regards medium-sized hemorrhagic fibromas as the special
field of radium and also cases in which, from weakness or other cause,
operation is inadvisable. In all other cases he prefers operation, par-
ticularly in young women when the fibroid is small, and can be removed
without interfering with the ovarian function.

Koenig2 considers uterine hemorrhage aside from those caused by
cancer and fibroids. In this group, he states, the regularity of cures
under radium is striking. For women over forty years it is the method
of choice, but for younger women it should be reserved for use after
the ordinary measures have failed.

Castano,3 of Argentina, reports his experience with the use of radium
in 250 cases of fibromas. His results were most encouraging.

Ross4 reports the case of a woman who developed typical asthmatic-
attacks following the use of radium to control severe uterine bleeding.
For a time the attacks were believed to be due to the artificial meno-
pause. All methods of treatment failing, Ross tried ovarian and
mammary extracts. The women showed improvement at once and
finally made a complete recovery.

It is well known that the roentgen rays have a marked action on
goiters. In the case of small goiters several applications will cause
their entire disappearance. Terry5 has made a second report on the
use of radium in the treatment of goiters. He states that the tubes
can be introduced easily into the thyroid gland under local anesthesia.
The amount of emanations and the number of tubes should vary accord-
ing to the size of the goiter and the intensity of the symptoms— from
4 to 10 millicuries, contained in from six to eight tubes. The emana-
tions are of value in preparing bad risk cases of exophthalmic goiter
for further surgical treatment, but should not be used in adenomatous
goiters.

In the treatment of toxic goiter, Lafferty6 states that medical treat-
ment (including all hygienic measures) accomplished results if used
very early, but the effects are greatly augmented by the use of radium.
Surgery will give the results, but should, as in other conditions, be

1 Gynecologie et Obstetrique, October, 1921.

2 Ibid.

3 Semana Medica, January 12, 1922; Abstract, Journal of the American Medical
Association.

4 British Medical Journal, January 7, 1922.

5 Journal of the American Medical Association, July 1, 1922.

6 Southern Medicine and Surgery, August, 1921.

384 LANDIS: THERAPEUTIC REFERENDUM

reserved as a last resort. Furthermore, radiation as a preoperative
measure in extreme cases is invaluable.

As a rule, the first symptoms to disappear are the nervousness and
sleeplessness, and this is followed by the improvement in the circulatory
system, though occasionally the order is reversed. Then gradually the
other symptoms disappear, except the tumor and the exophthalmos;
which leave slowly, if at all.

Laft'erty believes that radiation should be used, since it does give
relief and generally a cure, and since, if used properly, no harmful
results are obtained; it does not in any way preclude surgery later if
it is found that the case does not respond to radiation.

This would seem to be a distinct advantage over the roentgen rays,
which tend to produce adhesions and hence are objected to by surgeons
because it makes operative interference, if needed, more difficult.

Fischer1 reviews his results with radiotherapy in 490 cases of exophthal-
mic goiter. He states that the weight increases, sweating and diarrhea
and glycosuria, noted in 3 per cent, disappeared. Tachycardia was the
most constant symptom, and this disappeared entirely in 25 per cent,
and was materially modified in another 50 per cent. In the others the
pulse-rate ranged from 100 to 120, but the patients felt well. Exoph-
thalmos was the hardest to control; the effect was most marked in
those cases in which the exophthalmos was recent. Soft goiters yield
the soonest while the hard ones first soften and then slowly subside.

Care should be exercised in the severe cases as death may follow the
radiation.

Fischer states that, in his experience, radiation does not make sub-
sequent operative interference more difficult.

During the past year or so the most favorable reports have been
made in the use of the roentgen rays in the treatment of diseased tonsils.
Many of the reports indicate that this method of treatment is superior
to enucleation. It must be borne in mind that removal of the tonsils
is not, as many would have us believe, a trivial operaton In adults,
especially, it is to be regarded as a major operation, and one that may
be attended with serious dangers. Furthermore, we have come to
learn that the occurrence of pulmonary abscess following tonsillectomy
is becoming alarmingly frequent, especially in adults. If, therefore,
these dangers can be avoided, and equally satisfactory results obtained
by exposure of the diseased tonsil to the roentgen rays, a great advance
has been made.

Laft'erty and Phillips2 favor this method as against surgical treatment.
They state that it is safer, more effective and overcomes the objection
of the patient to the knife. Furthermore, the adenoid tissue of the
whole throat, the tonsils, postnasal adnoids and scattered adenoid
tissue in the pharynx is reached by this treatment.

Quick3 has treated 149 cases of malignant neoplasms of the tonsil

1 Ugeskrift for Laeger, April 13, 1922; Abstract, Journal of the American Medical
Association.

2 Southern Medical Journal, March, 1922,

3 Journal of Radiology, May, 1922,

SEBUM 385

with radium. His results are most encouraging. Thus, of 28 cases of
carcinoma of the tonsil reported clinically free from disease at present,
the average duration since the initial treatment is twenty-six months,
the longest being fifty-six months.

In 2 eases of sarcoma of the tonsil which I have seen, the greatest
relief from pain and the danger of starvation from obstruction was given

by exposure to radium. Even if these cases cannot be cured the evi-
dence so far at hand is greatly in favor of the method as a palliative in
inoperable cases.

Salicylates. The action of the salicylates in acute rheumatic fever
has been under discussion for several years. It is admitted that they
do afford relief to many patients while the medication is continued.
Whether they have a curative or bactericidal action has not been clear.
The most recent study has been contributed by Boots and Cullen.1
Using all the precautions necessary for the study of hydrogen-ion con-
centration, they found the joint fluids to be slightly alkaline. As a
definitely acid medium is necessary for the action of salicylic acid,
the latter cannot exist free in the joint fluids after the administration of
salicylates. Therefore, any advantage from their use in rheumatic
fever cannot be ascribed to bactericidal effects.

The untoward effects of the salicylates are generally traceable in
Caussade and ("harpy's2 opinion to impurities in the original salicylic
acid. They state there are only 10 cases on record of fatal intoxication
from their use.

Serum. A case of optic neuritis occurring in serum sickness is reported
by Mason.3 The patient was admitted to the hospital on the second
day after the onset of acute lobar pneumonia, Type I. During the
third, fourth, fifth and sixth days of the disease the patient received
500 cc of Type I antipneumococcus serum intravenously. Crisis on
the seventh day. Severe serum sickness appeared on the ninth day,
and was present for fourteen days. During the course of the serum
disease a well-marked, bilateral optic neuritis was observed. The
optic neuritis was not associated writh demonstrable visual disturbances.
At the end of three months the fundi had returned to normal in appear-
ance.

Search of the literature failed to reveal a similar case. He subse-
quently observed, however, 2 additional cases, showing mild grades of
optic neuritis without visual disturbances. One was a child given
antimeningitis serum and the other was an adult receiving Type I
antipneumococcus serum.

Carrieu4 observed a case of bilateral orchitis in a boy, aged thirteen
years, who had received diphtheria antitoxin. The orchitis was pre-
ceded a day by fever, an itching eruption and pain in the joints when
moved. The testicles remained painful and swollen for six days,
although the other evidences of serum sickness quickly subsided.

1 Proceedings of the Society of Experimental Biology and Medicine, March 15,
1922.

2 Revue de Medicine, March, 1921.

3 Journal of the American Medical Association, January 14, 1922.

4 Archives de me'decine des enfants, April, 1922.

386 LANDIS: THERAPEUTIC REFERENDUM

Anttanthrax Serum, llegan1 believes that, inasmuch as anthrax
in man is primarily a local infection, with a decided tendency to remain
as such, any treatment which tends through the barrier set up by
Nature is faulty. He advocates the use of serum both locally and
generally. The local injection of serum around the lesion every twelve
to twenty-four hours is a most desirable method to replace the local
measures until lately in common use.

Symmers, who has had a large experience with anthrax, has, for
some time, favored the use of serum locally and generally instead of
combined excision and serum.

Antianthrax serum is now marketed by Parke, Davis & Co., in
syringes containing 50 cc. The initial dose is from 50 to 100 cc, injected
intravenously, to be followed by further injections in six or more hours.
It is well to test the sensitization of the patient to horse serum, prior
to the first injection, by means of the cutaneous test, which will require
about half an hour. The drop of serum required for this test can
be obtained directly from the syringe container of antianthrax serum.

Antidiphtheric Serum. More and more the practice of giving
large doses of diphtheria antitoxin is becoming the accepted practice.
Bie2 gives from 4000 to 40,000 units in the milder cases, and does not
repeat the dose unless the membranes spread. In the severe cases he
employs doses up to 80,000 or 100,000 units to a total of 160,000 units
in the first twenty-four or thirty-six hours in children under ten years
of age, or 220,000 units in elder children. About 20 cc of the first
dose is given intravenously; all the other injections are given intra-
muscularly.

Bie states that since these large doses have been employed there
have been no deaths from respiratory paralysis, and the mortality in
the very gravest cases has been reduced from an average of 52 to 22
per cent. Furthermore, while the proportion of very severe cases
has doubled since 1896, the total mortality has declined from 2.6 per
cent in 869 cases in 1917 to 0.7 per cent in 1341 cases since these large
doses have been the rule. The less severe cases ran a harmless course.

Thomson3 states that, while attempts have been made to determine
the dose according to weight, the fact remains that the child requires
as large a dose as the adult. To arrive at the approximate dose, one
has to be guided by the stage of the disease, the rapidity of progress
from the onset of the symptoms, the amount of membrane, the amount
of inflammation and edema, the amount of glandular swelling, and
the amount of cellular infiltration. Also, whether the nasopharynx is
involved, as indicated by nasal discharge, and whether it is blood
stained; whether there is hemorrhage into the skin, and whether there
are subcutaneous hemorrhages and, finally, whether the larynx is
afl'ected and there is fetor. One should not be influenced by the amount

1 American Journal of the Medical Sciences, September, 1921; Abstract, Journal
of the American Medical Association, December 17, 1921.

2 Ugeskrift for Laeger, July 28, 1921; Abstract, Journal of the American Medical
Association.

3 Lancet, July 9, 1921.

SERUM 387

of membrane alone, as most serious cases often occur without any
membrane.

Thomson states that, having come to a probable estimate of the
dose, it is wise, in severe cases, to add about 4000 additional units to
cover possible error. He quotes Rolleston as recommending the follow-
ing doses: For severe faucial cases, 16,000 to 20,000 units, and a
similar or sometimes smaller dose on one or two of the following days.
For moderately severe faucial cases, 8000 to 12,000 units, occasionally
repeated on the following day. For mild faucial cases, 4000 to 8000
units, repetition rarely being necessary. For nasal, laryngeal, con-
junctival or aural diphtheria, in which there is no faucial involvement,
4000 to 12,000 units.

Thompson points out that ideally the amount of antitoxin necessary
should be given in one dose, but it is very difficult to estimate the
quantity, and so second doses are often required. It is desirable that
the second dose should be given not later than twenty-four hours
after the first, and repeated doses extending over a few days are not
to be recommended.

Antidysenteric Serum. The serum treatment of bacillary dysen-
tery in children is unfavorably reported by Josephs and Davison.1
In a series of 20 cases they were unable to see that the serum had any
influence either on the mortality or the course of the disease. Further-
more, in the very ill, especially in young infants, the pain at the site
of injection is a contraindication to the use of intramuscular injections.

Antipneumococcus Serum. Thomas2 reports on 60 cases of pneu-
monia, Type I, 50 receiving serum and 10 did not. In addition, he
reviews 550 cases reported in the literature exclusive of the Rockefeller
Institute series.

The material on which he bases his report indicates that Type I
pneumonia, however treated, varies in its mortality rate with the time
and place of its occurrence, and suggests that it may perhaps be not
so frequently fatal as is generally believed to be the case.

In his series of 50 serum-treated cases the serum (Type I) appeared
to shorten the disease in 4. In 8 the use of serum, though followed by
improvement in the symptoms, appeared to have only a transitory
effect. Among the remaining 38 patients, the duration and outcome
of the disease did not appear to have been demonstrably affected by
the serum.

Of the 50 cases receiving the serum the duration of fever was nine
and a half days; among those not so treated (10 cases) it was eight
and two-tenths days.

Ten patients of his series suffered from anaphylaxis and were relieved
by epinephrin. Of these 10 patients, 6 had previously shown no
reaction to dermal tests for sensitiveness to horse serum.

He believes that skin tests with the protein of horse epidermis, as
well as with that of horse serum, should precede the intravenous injec-
tion of the specific serum.

1 Journal of the American Medical Association, December 10, 1921.

2 Ibid., December 31, 1921.

388 LANDIS: THERAPEUTIC REFERENDUM

Serum sickness followed the use of Type I serum in 36 of 50 cases.
In 15 the symptoms were severe. Epinephrin allays the discomfort
of the eruption temporarily.

Antistreptococciis Serum. Of all the sera that have been employed,
the various forms (special types, polyvalent) of antistreptococcus serum
has been the least satisfactory. Dick1 reports a case of malignant endo-
carditis, in which various attempts were made to influence the condition
by means of antistreptococcus serum. He was forced to conclude that
the intravenous injection of fresh serum from a sheep immunized with the
patient's strain of Streptococcus viridans produced no benefit. Neither
did human serum from a person immunized with the patient's strepto-
coccus, given intravenously, aid. And, finally, fresh, whole blood
from a person similarly immunized was of no value when given sub-
cutaneously; but this whole blood did produce a definite temporary
improvement.

Antitetanic Serum. Although the use of this serum is of doubtful
curative value, its use as a preventive is firmly established. Stone2
emphasizes the fact that the most important factor in the treatment
of tetanus is its prevention. It should be the universal rule to give
a prophylactic dose of 1500 units of antitoxin to all patients who have
received lacerated or penetrating wounds. If the wound contains
necrotic tissue or a suspected foreign body the dose should be repeated
in ten days and subsequently if operation on the wound is contemplated.

As a matter of fact, I believe that this is now a generally recognized
procedure. The crusade inaugurated years ago by the American
Medical Association against Fourth of July injuries has resulted in
an extraordinary reduction of the incidence of tetanus. The lesson of
treating penetrating wounds, such as those produced by stepping on
a nail, has been thoroughly taken to heart.

Although the curative effect of the serum is of doubtful utility,
it should be used and in large quantities. Stone advises that if symp-
toms have appeared the attempt should be made to saturate the patient
with the antitoxin before fixation of the toxin has occurred in the nerve
cells of the spinal cord. This can best be accomplished by intraspinal
and intravenous injections during the first three days of treatment;
the total dosage, of which half should be given intra spinally, should
approximate 125,000 units.

Measles. The prophylactic use of serum obtained from immunized
patients has been reported by McNeal.3 Sixteen children, who had
been exposed to measles, received intramuscular injections of 5 cc of
serum obtained from healthy donors between the fifth and ninth days
after the disappearance of fever. Twelve of the children escaped the
infection, and 4 developed it in a mild form. As 1 child contracted
measles two months later, it suggests that the immunity does not
persist longer than sixty days.

McNeal believes that the method may prove of great value in pro-

1 Journal of the American Medical Association, April 22, 1922.
2 <Ibid.,* June 24^1922.
3, Ibid.,' February 4, 1922.

SODIUM BICARBONATE 389

tecting children during the period of danger, between the ages of five
months and six years, in tuberculous children and in those physically
below normal. Also in institutions it should prove of great value.

Silver. The use of silver nitrate in the treatment of asthma is reported
by Syme.1 He applies a 10 per cent solution of silver nitrate to the
mucous membrane of the bronchioles through a bronchoscope. He has
treated 23 patients, ranging in age from ten to sixty years. Eighteen
received the application on one occasion only, 4 on two and 1 on four
occasions. In 12 the benefit was so decided that no spasmodic attacks
of a severity sufficient to discommode the patient to any serious degree
occurred. In 2 there was no benefit, and in the remainder varying
degrees of relief were afforded.

In former years, when silver nitrate was a favorite remedy in the
treatment of gastric ulcer, cases of argyria were not uncommon, owing
to the prolonged use of this drug in some cases. Kimball2 reports the
case of a man, with duodenal ulcer, who had taken 10 minims of a 10
per cent solution of silver nitrate after meals for eighteen months.
Marked argyria resulted, associated with severe secondary anemia
and the presence of much albumen and fine granular casts in the urine.

In answer to a query as to whether silver arsphenanmie ever caused
argyria, the Journal of the American Medical Association replied that
2 cases had been reported. A few days after the injection the patients
noticed an ashen-gray discoloration of the skin, which rapidly became
more marked, finally assuming a steel-gray color. The sclera of the
eyes was also affected. Both cases were reported in the Therayentische
Ilalbmonatshcfte, June 15 and November 1, 1920.

Sodium Bicarbonate. The occurrence of tetany following the use of
sodium bicarbonate is reported by Healy.3 Of the 7 cases reported,
all were patients in whom a celiotomy had been performed for pelvic
trouble. There were 4 deaths and 3 recoveries. The onset of the
typical hand symptoms were observed as early as seven hours after
operation and the symptoms terminated within forty-eight hours,
either in response to treatment or by death of the patient.

The symptoms in the fatal cases were tachycardia, profuse dia-
phoresis, hyperpyrexia, epigastric distress, bilateral, symmetrical
spasms and contractions of muscles, especially of the upper extremities
and convulsions.

The source of the trouble was traced to the glucose and sodium
bicarbonate enema administered as a routine in most of the major
operative cases. This was supposed to contain 5 per cent glucose
and 5 per cent sodium bicarbonate in S ounces of water. This enema
was given as soon as possible after the return of the patient from the
operating-room and again in four hours. The first enema also con-
tained 40 grs. of sodium bromide. Through an error of calculation
1200 grs. of sodium bicarbonate was given instead of 180.

The last 3 patients recovered after the administration of sodium

1 Journal of Laryngology and Otology, September, 1921.

2 Ohio State Medical Journal, May, 1922.

3 American Journal of Obstetrics and Gynecology, August, 1921.

390 LANDIS: THERAPEUTIC REFERENDUM

lactate by mouth. The cases occurred irregularly over a period of
four months.

Sodium Lactate. The use of this drug in the treatment of acetonemia
is advocated by Madigliani,1 who claims that it does not cause intoler-
ance even given to infants up to 30 gms. per day. He has used it in
13 cases, giving from 12 to 30 gms. at first and then less in the following
three or four days. The urine becomes alkaline by the second day in
all, and the tests for acetone were negative by the third or fourth day.
Headache, vomiting, fever, dyspnea and the odor on the breath promptly
subsided.

The sodium lactate can be generated at the time by mixing in 30
cc of hot water two tablespoonfuls of 10 per cent solution of lactic acid
in distilled water, and two tablespoonfuls of a 7.5 per cent solution of
sodium bicarbonate.

Sodium Morrhuate. The use of this cod-liver oil derivative has been
used in the treatment of tuberculosis. Davies2 is convinced that many
of his patients have derived considerable benefit from its use.

Sulphonal. In an article on the uses and doses of hypnotics, Wyatt-
Smith3 states that sulphonal, except for its high price, is the best, and
that, in addition, it is a decided mental sedative. It appears to be
quite safe in doses up to at least 1 dr. a day, given in individual doses
of 30 grs. night and morning, or, better, of 20 grs. three times daily.

Tikitiki Extract. This is the active principle of rice polishings.
There are two grades of rice polishings or tikitiki, one from the light-
colored or white rice, and the other from red rice. The latter did not
give satisfactory results experimentally. Wells4 states that tikitiki
extract has shown that it possesses a high percentage of neuritis-pre-
venting substances and that it is a cure for infantile beriberi.

Tuberculin. During the past year the editor of the Therapeutic
Gazette (March and April, 1922) sent out a questionnaire on the treat-
ment of tuberculosis. In regard to the use of tuberculin, the best that
can be said of the answers submitted is that this agent is of value in
the pulmonary form of the disease. Most of the answers were unfa-
vorable, or hedged about with qualifications as to the time and type of
case it should be employed in. One or two observers still retained
their enthusiasm. There can be no doubt that the past ten years has
seen a great change of faith in the use of this agent.

Fischel5 admits that tuberculin has not wholly satisfied the hopes
originally cherished for it. He ascribes this to a failure to recognize
the disease sufficiently early to obtain the results that tuberculin is
capable of giving.

Turpentine. For the control of severe hemorrhage following the
extraction of teeth, Steadman6 recommends turpentine. The method

1 Rivista di Clinica Pediatrica, March, 1922; Abstract, Journal of the American
Medical Association.

2 Indian Medical Gazette, August, 1921.

3 Practitioner, September, 1921.

4 Philippine Journal of Science, July, 1921.
8 Tubercle, September, 1921.

6 British Dental Journal, April 1, 1922.

VACCINES 391

of application is simple. The gauze is soaked in the oil of turpentine

and the socket packed; if necessary, it is kepi in place by stitching or
by applying a pad over the gum and bandaging the jaws. Steadman
adds that oil of turpentine is a powerful antiseptic, and that after the
plug is removed the sockets retain a faint smell of turpentine and are
clean and free from infection. This is in striking contrast to the usual
experience after plugging, when the socket is generally septic and takes
a long time to heal.

Vaccines. Pertussis. Reports on the efficacy of pertussis vaccine
are conflicting; some are very enthusiastic— others, adverse. Davies,1
in an experience with 33 children suffering from whooping-cough, states
that, although it appears that the individual child responds differently
to the vaccine, the duration of the disease is shortened by the adminis-
tration. The duration in light, uncomplicated cases is given as from
eight to twelve weeks; the more severe cases last a longer period.
Paroxysms were lessened in severity and duration, and whooping
and vomiting were alleviated. The most severe reactions occurred in
children with valvular heart lesions.

Auricchio,2 in tabulating the results obtained in 196 cases, states
that only 14 did not show benefit from the treatment, while 67.8 per
cent wrere cured, and 26 per cent were improved. In the 6.2 per cent,
in which no benefit was obtained, the disease was either far advanced
or other pathologic conditions interfered with the vaccine therapy.

Paterson and Smellie3 found no special benefit from the use of vac-
cines. They believe that the most valuable aids in shortening the
disease and relieving the severity of the symptoms, are allowing the
child to run about in the open, frequent feeding of small amounts of
food and the use of cod-liver oil.

Typhoid. When the practice of employing typhoid vaccination
came into use the charge was made from time to time that it was
frequently followed by active tuberculosis. This has been thoroughly
disproved. Now the extraordinary charge is made by an anti-
vaccinationist, one Walter R. Hadwen, of England, that typhoid vac-
cination had resulted in the causation of enormous numbers of heart
disease among British soldiers. He has asserted in two public addresses
that the British Government was paying $20,000,000 per year in pension
to soldiers invalided and discharged from the British Army for heart
disease, and that nine-tenths of these cases were due to typhoid vaccina-
tion.

As pointed out in an editorial article,4 the Director-General of the
British Army Medical Service entirely disproved these assertions inso-
far as heart lesions are concerned. As the result of a special study,
long before the charges of Hadwen were made, the heart cases wTere all
satisfactorily accounted for. It is furthermore of interest to note the
results of typhoid vaccination in reducing the incidence of typhoid

1 American Journal of the Diseases of Children, May, 1922.

2 Pediatria, November 15, 1921.

3 British Medical Journal, May 6, 1922.

4 Journal of the American Medical Association, February 11, 1922.

392 LANDIS: THERAPEUTIC REFERENDUM

fever. In the Boer War, from 1899 to 1902, with a mean annual
strength of 208,226 men, there were 57,864 eases of typhoid fever
and 8022 deaths, and annual death-rate of 14.6 per cent. In the World
War, with a mean annual strength of 2,000,000, or almost exactly ten
times as many men as in the Boer War, there were only 20,139 cases
of typhoid fever and 1191 deaths, an annual death-rate of 0.139 per
cent, or less than one one-hundredth of the death-rate of the Boer War.
In our own army, General Ireland states, out of a total of 4,128,478 men,
from April 1, 1917, to December 31, 1919, there were 1529 cases of
typhoid fever and 227 deaths, or 0.0054 per cent.

Venesection. We have pointed out in former issues of Progressive
Medicine the fact that relatively few of the present generation realize
the value of venesection. Once the panacea for all ailments, it became
so thoroughly discredited that it is seldom resorted to today. Peterson
and Levinson1 advocate the employment of venesection in lobar pneu-
monia. They state their reasons as follows: Briefly, it may be stated
that in the exudate of the consolidated lung a balance exists between
the amount of enzyme present and the antiferment of the plasma and
tissue exudate. Early in the disease the leukocytes at the focus are
living and have not shed their enzyme content. As they die, the
enzymes diffuse into the surrounding mediums. If at any time the
enzyme concentration overbalances the inhibition of the tissue fluids,
active proteolysis will commence and the crisis ensue. If in place of
this increase in the enzyme concentration we can diminish the amount
of the antiferment, the same augmentation of proteolysis will be brought
about. This may take place, increasing the acidity of the exudate, or
actually diminishing the amount of plasma present in the exudate.

It is at once apparent, they believe, that venesection may have a
direct influence on this balance. The depletion of the fluids in the
vascular beds results in a prompt compensation by means of fluids
drawn from the tissue spaces. This will somewhat diminish the amount
of antienzyme. Again, it is to be remembered that the serum after
bleeding has less antiferment than normally, i. e., the fluids reaching
the focus would have less inhibiting substance than before. So, too,
diminution in alkali reserve would tend to increase the acidity of the
exudate.

In the opinion of Peterson and Levinson, we have, therefore, at
least three alterations following phlebotomy that seem of importance
in directly influencing the ferment, antiferment balance of the exudate
in the direction of acceleration of proteolysis.

Zinc. The use of talcum as a dusting powder in the toilet of infants
has been replaced, to a great extent, by stearate of zinc. Curiously
enough, this last-mentioned substance is not without danger. Herman
and Aschner2 have called attention to the fact that disastrous results
have occurred as the result of the aspiration of this powder. They
have studied 12 cases and, in addition, have noted the effects of stearate
of zinc insufflation in animals.

1 Journal of the American Medical Association, January 28, 1922.

2 American Journal of Diseases of Children, June, 1922.

zinc 393

The onset of trouble is sudden and stormy, with rapid respirations
and cyanosis. Complete asphyxia may occur. In 8 cases the initial
partial asphyxia was followed by a gradual recovery without definite
involvement of the lungs. The rapid respirations and cyanosis, which
followed immediately on the inhalation of the powder, subsided during
the course of three days.

It is known that insufflation pneumonia may be produced by non-
infective particles. Evidently, the pneumonic lesions due to zinc
stearate are analogous in origin. Talcum is less dangerous and more
easily expelled if inhaled.

Herman and Aschner believe that the zinc stearate container, with
its large perforations, as now used in the nursery, is a distinct menace
to the health of infants and should be banished.

INDEX.

Abscess, bone, chronic, 282
Acacia, 309

intravenous use of, 251
Acetonemia, sodium lactate in, 390
Acetylsalicylic acid, 310

in acute pharyngitis, 310
change in, in sodium citrate

solution, 310
in tonsillitis, 310
Acid, acetylsalicylic, 310
carbolic, 367
hydrochloric, 351
Actinomycosis, human, 194
Actinotherapy, 349
in neuralgia, 350
in neuritis, 350
Action of salts on liver after introduction

into duodenum, 88
Adrenalin, 311

in asthma, 311

effect of, on blood-pressure, 311
in heart block, 311
in polyneuritis, 311
Alcohol, 311

wood-, poisoning, 312
Alkali treatment of wood-alcohol poison-
ing, 313
Allonal, 315

in insomnia, 315
in pain, 315
Aloin reaction, 22
Aluminum silicate, 354

in Asiatic cholera, 354
Ammonium chloride, 315

in tetany, 315
Amoebic hepatitis, non-suppurative, 77
Anemia, iron in, 353

pernicious, hydrochloric acid in, 351
Anesthesia, ether, heat losses during, 224
ethyl chloride, death following, 224
local, 225

by-effects and after-effects of,
225
oxygen need during, 223
spinal, accidents with, 226
indications for, 226
Anesthetic properties of pure ether, 223
Aneurysm, mycotic, of femoral artery,

245
Angina pectoris, nitrites in, 363
Anthrax, 191

serothapy of, 194
Antianthrax serum, 386

Antidiphtheritic serum, 386
Antidysenteric serum, 387
Antimony, 315

in bilharziasis, 315
Antipneumococcus serum, 387
Antistreptococcus serum, 388
Antitetanic serum, 388
Antitoxin in tetanus, 201
Apocynum cannabinum, 316

in auricular fibrillation, 316
Appendiceal disease, 19
Appendicitis, 101

acute, 102

and cholelithiasis, relation between
ulcer of duodenum and, 731

chronic, 101

cecocolic lesions in, 106
diagnosis of, 103

deceptive forms of, 103

pain in diagnosis of, 104

vagaries associated with, 104
Arthritis, infectious, chronic, 296

protein therapy in, 374

of spine, infectious, 285
Arthrodesis of shoulder joint, deltoid

paralysis and, 297
Aseptic and antiseptic surgery, 209
Aspirin, 310

Asthma, adrenalin in, 311
Atropine, effect of, on gastric motility, 30
Atypical phenomena of gastric ulcer, 18
Auricular fibrillation, quinidine in, 377

Bacillus acidophilus, 316

in chronic diarrhea, 316
in colitis, 316
in constipation, 316, 317
in dermatitis, 316, 317
in eczema, 316, 317
in sprue, 316
Backache, syphilitic, 283
Bacteriology of fasting stomach and duo-
denum, 42
Barbital, 317

acute poisoning by, 317
Barium meal in gall-bladder diseases, 98
Benzidine reaction, 22
Beriberi, tikitiki extract in, 390
Betanaphthol, 318

as a vermicide, 318
Bile-ducts, injection of, with bismuth
paste, 97

396

INDEX

BilharziasiSj antimony in, 315

emetine in, 339
Biliary drainage, non-surgical, 91

lithiasis, gastric symptoms associated
with, 87
Bladder, cancer of, diathermy in, 160
radium in, 161
diseases of, 158
tumors of, malignant, 158
Blood changes in a gastrectomized patient
simulating pernicious anemia, 65
citrated, types of cases unsuited for,

250
extravasated, reinfusion of, 250
occult, in digestive tract, 21
t ransfusion, choice of methods of, 248
factors in reactions after, 250
in severe burns of infants, 248
Blood-pressure, effect of adrenalin on, 311
findings in circulatory disorders of
extremities, 243
Bolus alba, 354
Bone abscess, chronic, 282

density, studies in reduction of, 258
lesions, diagnosis of, by roentgen ray,

277
tuberculosis of, 278
Bone-grafting, 259
Bones, fractures of, forearm, 265

of leg, involving ankle, 271
of long, near large joints, sus-
pension-traction, treatment of
268
long, osteomyelitis of adolescent, 278
sarcoma of, 293
tumors of, 289
pelvic, osteomyelitis of, 282
Botulism, 327

treatment of, 329
Bromides in epilepsy, 318
Burns, severe, in infants, blood trans-
fusion in, 248

Calcium, 318

salts in tuberculosis, 318
Calculus, renal, 152

urethral, impacted, 181
Caloric food intake, 330
Camphor, 319

in sciatica, 319
Canadian hemp, 316
Cancer of bladder, diathermy in, 160
radium in, 161
of esophagus, radium treatment of,

32
gastro-intestinal, effect of secretion

on formation of, 67
of stomach, 66

analysis of, and its association
with preexisting ulcer, 66
Carbolic acid, 367

in erysipelas, 367
Carbon tetrachloride, 319

in hookworm infection, 126, 319
Carcinoma of prostate, 162

Cardiac arrhythmia, digitalis in, 338
insufficiency, ouabain in, 307
oxygen in, 366
( 'are, preoperative, 226
Catarrh, tubal, dibromine in, 324
Causalgia treated by decortication of

artery, 243
Cecocolic lesions in chronic appendicitis,

106
Cerebral activity, influence of, on secre-
tion of gastric juice, 36
Charcot's spine, tabetic, 284
Chaulmoogra oil, 320

in leprosy, 320, 322
in tuberculosis, 321
in tuberculous laryngitis, 321
China clay, 354
Chinosol, 323

in erysipelas, 323
Chronic bone abscess, 282
infectious arthritis, 296
intestinal indigestion, 123
Creosote, 324

poisoning, 324
Cocaine, 323

erythema from, 323
Cod-liver oil, 323

in rickets, 323
Colitis, bacillus acidophilus in, 316
ulcerative, 106
chronic, 113
Colon, 107

malignancies of, 116
peristalsis of, 107
Compensation, failure of, rest in, 344
Convallaria majalis, 316
Constipation, 111, 126

bacillus acidophilus in, 316, 317
Corpus luteum, 324

in vomiting of pregnancy, 324
Cotyloid cavity, fractures of, by enforce-
ment and central luxation of femur, 273
Cystography, 161
Cysts, synovial and tuberculosis, 297

Decapsulation for nephritis, 152
Defects of patellar border, 294
Delayed union of fractures, 277
Deltoid paralysis and arthrodesis of

shoulder joint, 297
Dermatitis, bacillus acidophilus in, 316,

317
Diabetes, obesity and, 331
Diarrhea, chronic, bacillus acidophilus in,

316
Diathermy in cancer of bladder, 160
Dibromine, 324

in leucorrhea, 324

in metritis, 324

in tubal catarrh, 324

in vulvar pruritus, 324
Diet, 325

Dietetic treatment of gastric ulcer, 57
Dietotherapy, postoperative, 226
Digestion, spleen and, 130

INDEX

397

Digestive disturbances, extrinsic factors
inducing, L9
symptomatology, interpretation of,

' is
t racl , diseases of, 17

minor ailments of, recognition

and treatmenl of, '11
occult blood in, 21

tests for, 22
roentgen-ray investigation of,
28
Digitalis, 336

in cardiac arrhythmia, 338
preparations, potency of, 33S
Dislocation of foot, posterior, 274
of lower end of ulna, 29 I
of patella, recurrent, 302
Diverticula, 115
duodenal, 75

of esophagus, diagnosis of, 31
treatment of, 31
Drugs in urology, 184
Duodenal diverticula, 75

obstruction, gastric and duodenal

motility in, 73
secretion, enzymatic activities of, 74
tube, accessory uses of, 35
ulcer, 47
Duodenum, action of various salts on
liver after introduction into, 88
fasting, bacteriology of, 42
intubation of, 76

ulcer of, relation between appendi-
citis and cholelithiasis, 73
visualization of, 76
Dupuytren's contraction of palmar fascia,

pathogenesis of, 255
Dysentery, emetine in, 340
Dysmenorrhea, Pulsatilla in, 375

Eczema, bacillus acidophilus in, 316, 317

Education, medical, 189

Embolectomy in treatment of embolism
. of extremities, 247

Emboli and embolic gangrene, 247

Emetine, 339

in bilharziasis, 339

Emotion, extreme, exhaustion produced
by, 220

Endocrines, 341

End-results of nerve-grafting, 257

Enteritis lamblia, 125

Enzymatic activities of duodenal secre-
tion, 74

Epicondylitis, existence and treatment
of so-called, 285

Epilepsy, bromides in, 318
luminal in, 355

Epiphysis of femur, upper, osteochon-
dritis of, 288

Epithelioma of penis, 171

Erysipelas, chinosol in, 323
phenol in, 367

Erythema from use of cocaine, 323

Erythrocytes, transfused, length of life of,
250

Esophagus, cancer of, radium treatmenl
of, 32
diverticula of, diagnosis of, ■">!

(real meiit of, 31

roentgen-ray examination of, 31
Ether, 342

anesthesia, beat losses during, 224
anesthetic properties of pure, 223

Ethyl chloride anesthesia, death follow-
ing, 224

Examination of feces, 110

Exercise and rest, 342

Exhaustion produced by extreme emo-
tion, 220

Extremities, surgery of, 185

Extrinsic factors inducing digestive dis-
turbances, 19

Factors in reactions after blood trans-
fusions, 250
in wound healing, 208
Fats and lipoids, physiology of, 111
Feces, examination of, 110
Femoral artery, mycotic aneurysm of,
245
thrombosis, operative treatment of,
247
Femur, neck of, fractures of, 273
Fibroids, uterine, radium, in, 382
Fistula following ureterotomy, 158
Flat-foot and rheumatism, 306
Food infection, acute form of, 326
intake, caloric, 330
in relation to gastro-intestinal dis-
orders, 325
Foot, posterior dislocation of, 274

scaphoid bone of, isolated disease of,
286
Forearm, fractures of bones of, 265
Fractures, 260

of bones of forearm, 265
of cotyloid cavity by enforcement
and central luxation of femur, 273
delayed union of, 277
of leg bones involving ankle, 271
of long bones near large joints, sus-
pension-traction treatment of, 268
of lower end of radius, reduction of,

265
of neck of femur, 273
non-union of, 277
of os ealcis, 274
of scaphoid bone, 266
spiral, mechanics of reduction in

treatment of, 266
of transverse processes of lumbar
vertebrae, 264
Functional testing of liver, 78

Gall-bladder, 89

diseases, barium meal in, 98

genesis of, 89
symptomatology, 18

398

INDEX

Gangrene, embolic, 247
Gas poisoning, oxygen in, 364
Gastric acidity, methods of measuring, 68
cancer, 66

analysis of, and its association
with preexisting ulcer, 66
contents, value of fractional analysis

of, 68
disturbances, functional, 38

postoperative, 38
juice, 68

influence of cerebral activity on
secretion of, 36
motility, effect of atropine in, 30
mucous membrane, histology of, 35
symptoms, 37

associated with biliary lithiasis,
87
tetany, 43
ulcer, 47

roentgen-ray diagnosis of, 48
Gastroenterostomy, 61

disturbances associated with, 63
duodenal reflex after, 62
end-results of, 64
studies on physiology of, 64
symptoms of marginal ulcers follow-
ing, 62
unfavorable symptoms after, 62
vomiting after, 62
Gastro-intestinal tract, roentgen-ray ex-
amination of, 31
Gastro-jejunal ulcer, cause and prevention

of, 61
Genesis of gall-bladder, 89
Goiters, roentgen rays in, 383
Gonococcal infection of kidney, 153
Gynocardate derivatives, 320

Heart block, adrenalin in, 311

disease, exercise in, 343
Heat losses during ether anesthesia, 224
Heliotherapy, 344

in lupus, 349

in rickets, 345

in tuberculosis, 348
Hemin crystals, microscopic determina-
tion of, 23
Hemorrhage, gastric, 18

turpentine in, 390
Hemorrhagic osteomyelitis, 292
Hepatitis, amoebic, non-suppurative, 77
Hexamethylenamine, 351
Histology of gastric mucous membrane,

35
Hookworm infection, treatment of, with

carbon tetrachloride, 126, 319
Hot and cold applications to surface of

body, effects of, 218
Human actinomycosis, 194
Hydrochloric acid, 351
Hypertension, water-drinking and, 336
Hypertrophy of prostate, 168
Hypospadias, 179

Indigestion, intestinal, chronic, 123
Infants, blood transfusion in severe burns

of, 248
Infection, food, acute form of, 326

of kidney, gonococcal ,153

lamblia intestinalis, 125
Infectious arthritis, chronic, 296
Inflation, perirenal, 156
Insomnia, allonal in, 315
Intestinal flora, transformation of, 120

nervous mechanism, 109

obstruction, acute, 118

tube, new, 43
Intestine, small, diverticula of, 115
Intracranial serotherapy in tetanus, 206
Intramuscular administration of sodium

citrate, 252
Intravenous use of acacia, 251
Intrinsic derangement of knee-joint, 299
Intubation and visualization of duo-
denum, 76
Iodides, 352
Iodine, 353
Iron, 353

in anemia, 353

Jejunal ulcer, cause and prevention of,

61
Joint lesions, diagnosis of, by roentgen
ray, 277
shoulder, arthrodesis of, deltoid
paralysis and, 297

Kaolin, 354

in asiatic cholera, 354
Kidney, gonococcal infection of, 153

movable, 147
Kidneys, diseases of, 147

mortality rate in, 147
postoperative results in, 147
Knee, results of extensive resections of,

in war surgery, 305
Knee-joint, intrinsic derangement of, 299
loose bodies in, removal of, postero-
lateral incision for, 300
septic, treatment of, 305

Lamblia enteritis, 125

intestinalis infection, 125
treatment of, 125
Laryngitis, tuberculous, chaulmoogra oil

in, 321
Lavage of renal pelvis, 153
Leprosy, chaulmoogra oil in, 320, 322
Leucorrhea, dibromine in, 324
Levulose as a test for hepatic insuffieienev

INDEX

399

Light, physiologic and therapeutic action

of, 214
Lily of the valley, 316
Lithiasis, biliary, gastric symptoms as-
sociated with, 87
Liver, 78

functional test ing of, 78
Local anesthesia, '_''_'.")

by-effects and after-effects of,
' 225
Luminal in epilepsy, 355
poisoning, 358
sodium, 355
Lung affections, postoperative, 231

emboli postoperative thrombosis and,
238
Lungs, collapse of, massive, postoperative,

231
Lupus, heliotherapy in, 349
Luxation, antero-lateral, of vertebral col-
umn reduced by operation, 306

Magnesium sulphate, 359

poisoning, 359
Malaria, quinine in, 376
Malignancies of colon, 116
Malignant, disease, radium in, 381
Manipulations of stiff joints, 294
Measles, serum in treatment of, 388
Mechanics of reduction in spiral fractures,

266
Mechanism of lowered resistance follow-
ing exposure to lowered temperature,
219 >
Medical education, 189
Mercurial stomatitis, 359
Mercury, 359

in syphilis, 359

untoward effect of, 362
Methylene blue, 362
Metritis, dibromine in, 324
Microscopic determination of hemin

crystals, 23
Mortality rate in diseases of kidneys, 147
Motor phenomena in normal stomachs,

40
Movable kidney, 147
Mumps, pancreatitis following, 99
Mycetoma, 195

diagnosis of, 197

etiology of, 196

pathology of, 196

symptomatology of, 196

treatment of, 197
Mycotic aneurysm of femoral artery, 245
Myeloma, multiple, 293
Myositis, 253

ossificans, 253

Nephrectomy, accidents occurring with,

148
Nephritis, 13]

Nephritis, clinical data of, 132

decapsulation for, 152

functional data, 132

infectious origin of, 140

influence of arterial hypertension in,
145

pericarditis in, 138

treatment of, 146
Nephroureterectomy, indications and

teehnie for, 151
Nerve-grafting, end-results of, 257
Nerves, peripheral, repair of, 255
Nervous mechanism, intestinal, 109
Neuralgia, actinotherapy in, 350
Neuritis, actinotherapy in, 350
Nicotine, 362
Nitrites, 363

in angina pectoris, 363
Non-suppurative amoebic hepatitis, 77
Non-union of fractures, 277
Nutrition classes, 330

Obesity and diabetes, 331
Obliterating thrombo-angiitis, 245
Obstetrics, pituitrin in, 369
Obstruction, duodenal, gastric and duo-
denal motility in, 73

intestinal, acute, 118
Occult blood in digestive tract, 21
Operative treatment of femoral throm-
bosis, 247
Opium, action of, on stomach, 46
Optic neuritis in serum sickness, 385
Orthoform, 364
Os calcis, fractures of, 274
Osteitis fibrosis cystica, 294
Osteochondritis of upper epiphysis of

femur, 288
Osteomyelitis of adolescent long bones,
278

hemorrhagic, 292

of pelvic bones, 282
Ouabain, 367

in cardiac insufficiency, 367
Oxygen, 364

in cardiac insufficiency, 366

in gas poisoning, 364

in lethargic encephalitis, 366

need during anesthesia, 223

in pneumonia, 365

Pain, allonal in, 315
Pancreas, 99

disease of, roentgen-ray studies in,
101

syphilis of, 99

tumors of, 100
Pancreatic conditions, 19
Pancreatitis following mumps, 99
Paralysis, deltoid, and arthrodesis of

shoulder joint, 297
Parotitis, secondary, 239

11)0

INDEX

Patella, dislocation of, recurrent, :!<•'-' Pseudocoxalgia, 288
Patellar apex, tuberculosis of posterior Pulsatilla, 374
surface of, 278
Ix.nlcr, defects of, 294
Pathogenesis of Dupuytren's contraction Pyramidon reaotion, 22

of palmar fascia, 255
Pellagra, 332
Penis, diseases of, 171

cpit belioma of, 1 71
Pepsin, action of, on motor function of

large intest ine, Ki7
Perforat ion, gastric. L8
Periarterial sympatneticus, 2 1 1
Pericardii is in nephritis, I 38
Perirenal inflat ion, I "><>
Peristalsis of colon, 107
Peritonitis, L28.
Pertussis vaccine, • !'••!
Pharyngil is, acute, aspirin in, 310
Phenol, 367.

in erysipelas, ^<>7
Phenolphl balein, 367
react ion, '~l

skin eruptions following use of, -!ii7
Phosphorus, 368

poisoning, 368
Physiologic acl ion of bght , _'l I
Physiology, renal, I 1 1
Pituitary extract, 368

in diabetes insipidus, 369
in enuresis, 369

influence of, on gastrointes-
tinal tract, '-'I
in obstetrics, 369

Pil nil rin in ohslel rics, 369

Pneumonia, lobar, venesect ion in, ii'.iii

gen m, 365
Poisoning by quinine, ;'>77
h\ wood-alcohol, -\\ 2

alkali i real men! of, 313
unusual complication fol-
low ing, ■!! '■'<
Polyneurit is, adrenalin in, 31 1
Postoperative complications, 226
dietol berapy, 226
lung affect ions, 231
massive collapse of Lungs, 231
results in diseases of kidneys, I 17
thrombosis and lung emboli, 238
Potassium, nil rate, •!7){

in osteomyelit is, 373
poisoning, 373
permanganate, :!7:'.
in smallpox, 373
Pregnancy, vomiting of, corpus lutcum

in, 324
Preoperative rare, 226
Procaine, 37 1

in dermal itis, \\l I
Prostate, diseases of, 162
carcinoma of, L62
hyperl rophy of, His
Prostatectomy, perineal, new method <>l
performing, 168

in dysmenorrhea, 375
Pylorospasm, in adults, 1 1

Quinidine. :i77

in auricular fibrillat ion, ^77
Quinine, 376

in malaria, 376

poisoning, -i77

Radii m, 381

in malignant disease, 381

in i real meiii n!' cancer of esophagus,

32
in uterine fibroids, 382
Radius, fractures of lower end of, reduc-

i imi ui', 265
Reactions after blood transfusions, fac-
tors in, 250
Reinfusion of extravasated blood, 250
Relation between ulcer of duodenum,

appendicitis and cholelithiasis, 7;i
Renal calculus, 152

diagnosis, funct ional, 17) I

lests ill, I.") I

pelvis, lavage of, 153

physiology, I It
Rest , exercise and, '.\ 12

in failure of compensat ion, •! 1 1
Results <>i extensive knee resections in

war surgery, 305
Rheumatism, Qat-foo1 and, 306
Rickets, :;:'.'-'

hehol berapy in, '■'< [5
Roentgen rays, 381

diagnosis <>f hone and joint
lesions by, '-'77
ill diseased tonsils, 383
of duodenal nicer, 19
of gast rie ulcer, 18
examination of gastro-intcstinal

tract, :;i
in goiters, 383

picture, serration of greater curva-
ture of stomach in, 30

studies in pancreatic disease, KM

Protein, :;7 I

t berapy in art bril is, :;7 I

in t uberculosis. .17 I
Pruritus, vulvar, dibromine in, 324

S \i [CI LATB . 385

iti acute rheumat ic fever,

Salts, action of various, on liver alter

mi i . m hut ion inio duodenum, 88

Sarcoma of long hones, 293

Sea pi 10 ii| hone ol loot , isolated disease of,

286
frari ures of, '-'iti
Scial ica, camphor in, 319

Septic knee-joints, trealinenl of, 305

INDEX

inl

therapy of anthrax. 194
Serun

antianthrax.

antidiphtheriti

antidyBenteric, 387

antipneumococcus,

an' 388

antitetanic, 3S8

in ■ 188.

sickness, optic neuritis ii
Shock. 219
Shoulder joint, arthrodesis of, deltoid

paralysis ami. -
Silicate of aluminum, 354

in Asiatic cholera, 354
Smallpox, potassium permanganate in,

Sodium bicarbonate, 389

tetany following use of, 389
citrate, intramuscular administra-
tion of. 2.72
iodide, 352
lactate, 390

in acetonemia, 390
morrhuate, 390

in tuberculosis, 390
Spinal anesthesia, accidents with. 226

indications for, 226
Spine, arthritis of. infectious, 285

Charcot's, tabetic, 284
Spleen, 130.

and digestion, 130
Sprue, bacillus acidophilus in, 316
Standardization of test-meal, 72

lardized results of wound healing,
209
Stomach, action of opium on, 46
cancer of, 66

dilatation of, acute, as a postopera-
tive condition. 230
fasting, bacteriology of. 42
motor phenomena in normal, 40
ulcer of. 47
Studies in reduction of bone density, 258
Sulphate of magnesium, 359

poisoning, 359
Suppuration, acute, treatment of, 214
Surgical infection, general, 211

■ ilization of wound-. 213
Suspension-traction treatment of frac-
tures of long bones near large joints,
268
Synovial cysts and tuberculosis, 291
Syphilis, mercury in, 359

of pancreas, 99
Syphilitic backa'-hc, L"-:;

Tabetic Charcot's spine. 284

Test, for hepatic insufficiency, levulose as

a te8f for. 86
van den Bergh, in differentiation of

obstructive from other typ-

jaundice, 81
Teste for occult blood in digestive tract.

■ us, 197

intracranial serotherapy in. -
path 198

prophylaxis of. antitoxin in, 19
treatment of, 201

antitoxin in, 201
trismus in, prevention ";'. 205
Tetany, ammonium chloride in. 315

following use of sodium bicarbonate,

gastric, 43

Therapeutic action of Light, 21 1

referendum, 309
Thromboangiitis, obliterating. 245
Thrombosis, femoral, operative treatment
of, 247

postoperative, and lung emboli, 238
Thymolphthalein reaction. 22
Tikitiki extract. 390
in beriberi
Tonsillitis, aspirin in, 310
Tonsils, diseased, roentgen ray- in.
Transformation of intestinal flora. 120
Transfusion, blood, in severe burn- of

infants, 24^
Trismus in tetanus, prevention of, 205
Tube, duodenal, aci 35

Tuberculin, 390
Tuberculosis of bone. _7^

calcium salts in. !1 ^

chaulmoogra oil in. 321

heliotherapy in. 348

of posterior surface of patellar apex,
278

protein therapy in. 374

sodium morrhuate in, 390

-urgical, 206

non-operative treatment of, 206

synovial cysts and. 297
Tumors of bladder, malignant. 158

of lone bones. 289

of pancreas, 100

of urethra, primary. 177
Turpentine. 390

in hemorrhage. 390
Typhoid vaccine, 391

Ulcer, duodenal, 47

perforation of. acui

relation between appendicitis

and cholelithiasis and. 7
roentgen-ray diagnosis of. 19
treatment of.
gastric, 47

atypical phenomena of. 18
perforation of acute, 53
roentgen-ray diagnosis of. 4^
Sippy method of treating

of." 51
treatment of. 56
dietetic, 57
Ulcerative, <•< >lir i-. 106

chronic, 113
Ulna, lower end of. dislocation of, 294
Ureterotomy, fistula following. 158

402

INDEX

Urethra, tumors of, primary, 177
Urethral calculus, impacted, 181
Urology, drugs in, 184

Vaccine, pertussis, 391

typhoid, 391
Vaccines, 391
Venereal granuloma, 181
Venesection, 392

in lobar pneumonia, 392
Veronal, 317

poisoning by, 317
Vertebra, antero-lateral luxation of, re-
duced by operation, 306
Vertebrae, lumbar, fractures of transverse

processes of, 264
Visceroptosis, 24

normal incidence of, 24
Visualization of duodenum, intubation

and, 76
Vitamins, 332

Vomiting of pregnancy, corpus luteum in,
324

Wassermann reaction, its use in gastro-
intestinal cases, 19
Water-drinking and hypertension, 336
Wound drainage with dry and moist
dressings, 214
healing, factors in, 208

standardized results, 209
Wounds, actinotherapy in, 351
surgical sterilization of, 213

Yeast, 335

Zinc, 392

stearate, 392

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